i^i^.-v;'!vT^;v;t ;;: t s^.; -£ PS^Er-ff-2?:' &S -£»^-**^Sm^ NATIONAL LIBRARY OF MEDICINE Bethesda, Maryland '. •« • LIBRARYrOF THE NAVY DEPARTMENT. Section of Bureau of Medicine and Surgery. << f 5 500 Me 157 RhSL* A/i / V *- ESSAY ON GROWTHS IN THE/tlRYNX: /~. WITH REPORTS, AND AN ANALYSIS OFO^ ONE HUNDRED CONSECUTIVE CASES TREATED BY THE AUTHOR, A TABULAR STATEMENT OF ALL PUBLISHED CASES TREATED BY OTHER PRACTITIONERS SINCE THE INVENTION OP THE LARYNGOSCOPE. BY MORELL MACKENZIE, M.D. Lond., M.R.C.P. PHYSICIAN TO THE HOSPITAL FOR DISEASES OF THE THROAT, AND TO THE ROYAL SOCIETY OF MUSICIANS; AND SENIOR ASSISTANT-PHYSICIAN, AND LECTURER ON DISEASES OF THE THROAT, AT THE LONDON HOSPITAL. WITH NUMEROUS ILLUSTRATIONS IN CHROMO-LITHOGRAPHY AND WOOD-ENGRAVING. "'vsnsA ^J;^; PHILADELPHIA : LINDSAY & BLAKISTON. 1871. CNU/T) LONDON : WYMAN AND SONS, PRINTERS, GREAT QUEEN STREET LINCOLN'S-INN FIELDS, W.C. TO PROFESSOR CZERMAK, M.D. BY WHOSE GENIUS AND PERSEVERANCE THE LARYNGOSCOPE WAS BROUGHT TO PERFECTION ; BY WHOM A GROWTH IN THE LARYNX WAS FIRST SEEN WITH THE LARYNGEAL MIRROR ; AND WITHOUT WHOSE LABOURS THIS VOLUME COULD NOT HAVE BEEN WRITTEN : THESE PAGES ARE DEDICATED BY HIS OBLIGED FRIEND AND PUPIL THE AUTHOR. PREFACE. T N the year 1863, the Jacksonian Prize was awarded to -■- me for my " Essay on Diseases of the Larynx." It was my intention to publish that work at the time, but my in- creasing engagements prevented me from at once carrying out this project, and Laryngology made such rapid advances that the views of one year became almost an anachronism in the next. Under these circumstances, I determined to publish, from time to time, a series of monographs on Diseases of the Throat, based on my original Prize Essay, but brought up to the most recent date. For the subject of my first Essay I selected Nervo- Muscular Affections of the Larynx, on account of their very frequent occurrence and great importance ; and the great interest which attaches to Laryngeal Growths has induced me to choose this subject for my second Essay. Since Ehrmann published his classical Histoire des Polypes du Larynx, in the year 1850, the Laryngoscope has effected an entire change in our views, and it is thought that sufficient time has now elapsed to enable us to consider these diseases from the new standpoint. vi PREFACE. The present Essay is based on an experience of nearly 150 cases of laryngeal growth. It includes detailed Reports of 112 .cases, of which 26 have been previously published in the Medical journals or the Transactions of Medical Societies, and 86 are now brought forward for the first time. Of my 112 cases, 100 underwent treatment, and 12 were merely observed with the laryngoscope. The 100 cases are consecutive, no treated case having been intentionally omitted : jy of the cases were cured, in 18 improvement took place, in 3 the result was negative, and « 2 died. Of the fatal cases, one was an infant, and the other an adult. In both tracheotomy had bean performed. The circumstances of nearly every case, which I have successfully treated, are known to one or more medical practitioners, and in by far the greater number of cases, the growths have been removed in the presence of professional confreres. I have excluded all cases of carcinoma, although in some instances great temporary benefit has resulted from the more or less complete removal of such neoplasms ; and I have also excluded all cases of " false excrescence."1 I have likewise omitted a few other cases,—some because the notes were too imperfect to be of any value, some because they were only seen in consultation with other practitioners, and one because (no treatment having been advised by me) the case was subsequently reported by another physician. 1 See page 36. PREFA CE. VII There still remain a considerable number of true growths which have come under my care since June, 1870 ; but as for statistical purposes it was convenient to limit the number of cases treated to 100—a number probably sufficient to eliminate accidental circumstances—I have omitted all those subsequently seen. In addition to my own cases, I have appended a record of all the published cases which have been treated since the invention of the Laryngoscope : all sources available in this country down to the end of the year 1870 have ' been carefully searched. In this arduous work, which relates to cases not only in England and America, but to a much greater number in Germany, France, Russia, Italy, Austria, and Hungary, I have received great assistance from Dr. Jagielski and Dr. Baumler. > My thanks are due to my colleagues at the London Hospital, Dr. Andrew Clark and Dr. Fenwtck, for their kind assistance in the microscopic examination of many of my specimens, and to my brother, Mr. STEPHEN MACKENZIE, who has made careful microscopic drawings of the neoplasms removed by me during the last two years. I am also greatly indebted to my assistant, Mr. LENNOX BROWNE, for much valuable help in bringing out this work. All the laryngoscopic drawings made for me since the year 1867 have been taken from life by him with great fidelity and artistic skill, and he has made finished drawings of those which I myself had sketched at an earlier date. In addition to this, he has greatly aided me by taking notes of the greater number of my cases during the last four years. My former pupil and friend, Mr. Piigin THORNTON, has also VI11 PREFACE. given me valuable assistance by keeping records of many of my cases. Lastly, I have to thank the numerous medical friends who have brought so many of the patients under my notice, and those who, by their presence at my public demonstra- tions, have encouraged me to persevere in the treatment of these laborious and difficult cases. 13, Weymouth Street, Portland Place, W., June, 1871. TABLE OF CONTENTS. SECTION I. HISTORY.—Koderik, Lieutaud, Albers, Brauers, Regnoli, Ryland, Ehrmann, Rokitansky, Horace Green, Gurdon Buck, Middeldorpf, Prat, Astley Cooper. Invention of Laryngoscope. Increased Number of Cases observed ... SECTION II. CAUSES.—Influence of Chronic Hyperemia of the Mucous Membrane, Influence of Dyscrasias, Influence of Acute Diseases, Influence of the Inspiration of Irritating Vapours and Particles of Matter, Influence of Age, Influence of Sex, Influence of Occupation.................................... SECTION III. SYMPTOMS. — Functional Signs.— Modification of the Voice, Cough, Dyspnoea, Pain, Dysphagia. Physical Signs.—Laryngoscopic Signs of—Papillomata, Benign Epithelial Growths, Fibromata, Myxomata, Lipomata, Fasciculated Sarcomata, Cystic Growths, Adenomata, Angeiomata. Laryngeal Sounds and Crotchets. Digital Exploration. Forced External Elevation of the Larynx. Auscultation and Percussion of the Larynx. Microsco- pical Examination. Constitutional Condition. Course and Termination. Complications.............................. c x On Growths in the Larynx. SECTION IV. Page. DIAGNOSIS.—Eversion of the Ventricle, Syphilis, Condylo- mata, False Excrescences, Gummata, Elephantiasis, Lupus, Laryngeal Phthisis, Malignant Growths, Outgrowths ...... 34 SECTION V. PATHOLOGY—General Remarks —Papillomata—Relation of Papilloma to Warty Cancer—Benign Epithelial Growths —Fibromata—Fibro-Cellular Growths, or Mucous Polypi — Myxomata — Lipomata — Fasciculated Sarcomata — Cystic Tumours—Adenomata—Angeiomata—Other Kinds of Growth — Degeneration of Growths. Comparative Pathology ......................................................... 38 SECTION VI. PROGNOSIS.—In Relation to Life—Adults—Children—In Relation to Voice ................................................ 57 SECTION VII. TREATMENT.—Palliative—Radical—BY INTERNAL OR LARYNGOSCOPY TREATMENT. MECHANICAL TREATMENT—Preparatory Measures—Anaesthetics— Method of Procedure—Evulsion—Common Laryngeal Forceps—Tube-forceps—Crushing—Cutting—Cutting Forceps, Knives, Scissors or Shears, Ecraseurs, Wire Loops and Rings—No Danger in Ecraseurs or Wire Loops— Guillotines. CHEMICAL TREATMENT—Caustics, Escharotics, Galvanic Cautery. EXTRA-LARYNGEAL METHODS OF TREATMENT—Contra-Indications for —Division of the Thyroid Cartilage, or Thyro- tomy—Indications for Operation—History—Method of Procedure—Thyrotomy Table—Comparative Merits of On Growths in the Larynx. xi Page. Thyrotomy—In Relation to Life, In Relation to Voice, In Relation to Recurrence. Removal of Growths by Division of the Thyro-hyoid Membrane—Indications for Operation—History—Method of Procedure—Com- parative Merits of Operation. Removal of Growths by Laryngotomy or Tracheotomy—Indications for Operation, History, Method of Procedure. Comparative Merits of Operation. The Combined Method of Re- moving Growths (Tracheotomy or Laryngotomy being first performed, and the growth being subsequently removed by Laryngoscopy) ................................................ 60 APPENDIX A. Reports of One Hundred Consecutive Cases treated by the Author ............................................................... 107 APPENDIX B. Short Reports of a few Cases in which Radical Treatment was not adopted......................................................... 2°' APPENDIX C. Table of One Hundred Consecutive Cases treated by the Author ............................................................... 2°9 APPENDIX D. Table of all Published Cases treated by other Practitioners since the Invention of the Laryngoscope ..................... 227 Lithographic Plates II. III. IV. and V., with descriptions 249 INDEX ................................................................. 2i~i ESSAY ON GROWTHS IN THE LARYNX. BENIGN GROWTHS IN THE LARYNX. Definition :— New formations of benign character, forming projections on the mucous membrane of the larynx, generally giving rise to aphonia or dysphonia, often to dys- pnoea, and occasionally to dysphagia. Synonyms :— Latin.—Polypus Laryngis ; Tumor Laryngis. French.—Polype du Larynx ; Tumeur Polypeuse ; Tu- meur Verruqueuse ; Tumeur Fibreuse; Excroissance Epitheliale ; Vegetations' Papillaires ; Kyste Mu- queuse. German. — Larynxpolyp ; Fibrospolyp ; Bindgewebs- geschwulst; Papillargeschwulst; Schleimpolyp ; Neubildung. English.—'Polypus of the Larynx ; Fibrous Tumour ; Fibrous Growth ; Connective-tissue Growth ; Wart ; Warty Growth ; Excrescence ; Vegetation ; Cystic Tumour; etc. i ( 2 ) SECTION I. HISTORY. Isolated cases of laryngeal polypus are to be found from an early date, and the case in which Koderik success- fully operated on a growth through the mouth, about the year 1750,1 is one of the first described. Seventeen years later, Lieutaud2 published two cases of undoubted laryngeal polypus. In the beginning of the present century the Imperial Government of France offered a prize for the best work on Croup, and several eminent practitioners in different parts of Europe turned their attention to diseases of the larynx. 1 George Herbinaux, Parallele des differens Instruments, avec les Methodes de s'en servir pour pratiquer la Ligature des Polpyes dans la Matrice, en forme de Leitre a M. Roux, avec Figures. A la Haye, chez Gosse et Percl. 1771. This case is quoted by Lewin in his able and comprehensive article in the Deutsche Klinik, March 29, 1862. 2 "63. In cadavere cujusdam asthmatici triginta annorum, qui perpetuo quere- batur de quodam impedimento in trachea, quod tussi et screatu expellere saepius conabatur et morte subitanea sublati, reperitur quidam polypus variis radicibus laryngi infixus et versus glottidem obturamenti instar adactus, unde suffocatio inexpectata. " 64. Secto cadavere cujusdam pueri duodecim annorum jampridem phthisici et inexpectata morte rapti, in propatulum veniebat intra laryngem corpus quoddam polyposu7ti et racemosum tracheae superiori parte, pediculo unico et peculiari ortum trahens et hinc fluitans ; quo forte ad laryngem repulso suffocationem obierat seger."—Lieutaud, Historia Analom. med., lib. iv. observ. 63, 64. 1767. In reporting these cases, Ehrmann, in his classical Histoire des Polypes du Larynx (Strasbourg, 1850), remarks at page 5 as follows :—" Les deux observa- History. 3 Wc hence find a number of cases observed at this time, and subsequently published. Albers, of Bonn, one of the successful competitors, published an important work1 in the year 1833 ; and in the same year, Brauers, of Louvain, attempted to extirpate a laryngeal polypus by division of the thyroid cartilage. In 1836 Regnoli2 recorded a case in which he removed a growth from the larynx through the mouth, after performing tracheotomy ; and the following year Ryland3 devoted several pages of his classical work to tumours of the larynx. It was not, however, until the year 1850 that a complete monograph appeared. Then it was that Ehrmann published his celebrated treatise,4 which included thirty-one cases of laryngeal growth. In the year 18515 Rokitansky brought forward ten additional cases ; and in 1852 Dr. Horace Green/5 of New York, published thirty- nine cases, two of which had occurred in his own practice. In the following year, Dr. Gurdon Buck collected forty-nine cases, including his own interesting example; and in 1854 Middeldorpf7 brought together sixty-four cases. Finally, in the year 1859, P^t published a case in which he had removed a growth through the thyro-hyoid membrane.8 Amongst all these cases, there are only nine in which an attempt was made to remove the growth during life, and one of these, viz. that by Koderik, already referred to, is so vague, that it must necessarily be excluded. Of the remaining eight cases, in four "instances (those of Brauers, Ehrmann, tions de Lieutaud paraissent fort concluantes ; on voit que dans la premiere le mot asthmatici est souligne, ainsi que le mot phthisici dans la seconde ; n'est-il p;is probable que par cette simple marque typographique l'auteur ait voulu in- diquer que les polypes avaient simule, pendant la vie, les symptomes d'asthme et de phthisie qui en avaient impose aux medecins ?" 1 Dissert, de Tumorib. in Cavo Laryngis. Bonn. 2 Osservazion. chirurg., 2 and 5 there were 2 cases. 5 , 10 4 ,. 10 , 15 4 ,, 15 , 20 ,. 2 20 . 30 ,. 21 30 , 40 ,, 22 40 - 50 28 „ 5o , 60 14 ,, 60 » 70 3 » 100 These statistiscal results, based on cases actually treated, do not include two cases of supposed congenital growth contained in Appendix B. The facts contained in the tabular statement of my own cases are corroborated by an analysis of the ages of the patients in the hands of other practitioners. By reference to Appendix D, it will be seen that of 163 cases in which the ages are stated, no less than 112, that is 687 per cent., oc- curred between the ages of 20 and 50. The greatest age, at which a growth has been seen, occurred in the practice of Dr. Bruns. In one of his cases the patient was 74 years old.1 It is probable, however, that the actual number of cases of laryngeal growths in young children is much greater than my tables would indicate; for it is extremely likely that many cases of'growths in the larynx in young subjects are overlooked by practitioners who do not use the laryngoscope ; and, moreover, as in young subjects, the epiglottis is more pendent, growths, though present, may not be revealed even 1 Appendix D, Case 123 i6 On Grozuths in the Larynx. by the laryngoscope. Statistics as to age, mainly founded on the experience of the Hospital for Diseases of the Throat, are subject to a certain fallacy, inasmuch as young children are more likely to be taken to one of the numerous Children's Hospitals, now so conveniently situated in almost every part of London, than to the former Institution. It is worth noting here, that of the 34 morbid specimens collected in the various metropolitan museums, no less than 15 are from children under the age of 12 years. Influence of Sex.—As to sex, I find that of my 100 patients, 62 were males, and 38 females. Of 187 patients in the practice of other operators, whose sex is tabulated in Appendix D, 135 were males, and 52 females. These numbers show that neoplasms, like other laryngeal dis- eases, are more common in the male than in the female sex. This is, perhaps, partly due to the fact that, from the nature of their occupation, men are more exposed to the exciting causes of chronic hyperaemia. It does not, however, altogether explain the greater proclivity of the male sex ; for in Causit's 42 cases, in which the growth occurred in young children, before the influence of vocation could modify results, 28 occurred in males, and 14 in females.1 Influence of Occupation.—The examination of my tables (Appendix C) would seem to indicate that the professional use of the voice is one of the circumstances most favourable to the development of growths. Thus, if we except the occupations of gentlemen, merchants, and labourers, each of which embraces people subject to very different conditions, though they furnished respectively 2, 2, and 4 cases, it will be seen that a preponderating number belong to those who are constantly obliged to use their voice, no matter what may be the state of the vocal organ. Thus of the 53 males old enough to have an occupation, 6 were vocalists, 1 a clergy- man, 2 officers in her Majesty's service, 2 waiters, 1 a page, 1 a sailor, 2 hawkers, and 1 a railway porter whose duty in- 1 Op. cit. Causes.—Occupation. 17 volved constant shouting. There were also 3 females who professionally used their voice ; viz., 2 hawkers and 1 Scripture- reader. These embrace 21 per cent, of all my treated cases old enough to have an occupation.1 Of 105 cases (of the 189 tabulated in Appendix D) in which the occupation is stated, no less than 20 were people whose profession entailed the constant use of the voice. As a proof, however, that growths may arise from causes entirely independent of vocalization, attention is called to Case 37 in Appendix D, in which the patient was a deaf mute.2 The influence of occupation, in so far as it subjects people to the inspiration of irritating particles, has been already considered (pp. 12 and 13). Of my treated cases, 23 were engaged in out-door occu- pations,3 70 in in-door occupations, and in 7 the employment was of a mixed character. When it is remembered that the actual number of people employed out of doors in large towns is very much less than those engaged in in-door occupations, and also that, according to the general statistics of the Hospital for Diseases of the Throat (in which the majority of my cases occurred), those engaged in-doors furnish by far the greater number of cases,—it is all the more remarkable that laryngeal growths should be more prevalent among those employed in out-door occupations. This difference in the statistical conclusions may, perhaps, be explained by the fact that growths most frequently arise where people use the voice out of doors, as in the case of mili- tary and naval officers, hawkers, street-singers, &c. 1 As a matter of convenience, for statistical purposes, patients have not been considered to have an occupation before the age of fifteen years. 2 In referring to this case, I do not mean to imply that deaf mutes are entirely incapable of any vocalization, but that in their case vocalization is quite a secondary and unimportant function. 3 Of course, most of the women and children, and some of the men, had '' no occupation," and in considering the respective influence of external and internal atmospheric conditions, deductions are based on the supposition of the patient spending the greater part of his or her time either in-doors or out-of-doors. i J ( 18- ) SECTION I I I. SYMPTOMS. It will be readily understood, that, as a rule, the signs and symptoms of a growth in the larynx depend in their nature and degree upon the exact situation and size of the neoplasm. Thus a growth on the vocal cords causes aphonia, or hoarse- ness ; a growth on the epiglottis produces dysphagia ; and a large tumour, wherever situated, is likely to give rise to dyspnoea. Symptoms are functional* [alterations of voice, dyspnoea (including stridor and paroxysmal suffocation), pain, and difficulty of swallowing], and physical (furnished by laryn- goscopy examination, by the laryngeal sound, by digital exploration, by forcible external elevation of the larynx combined with depression of the tongue, by auscultation and percussion of the larynx, by examination of the ex- pectoration, and by the constitutional conditions). Functional Signs. Functional signs furnish very imperfect evidence, except to those who have had large experience of the cases under consideration. From the varying and peculiar character of the voice, the croupy cough, and the paroxysmal dyspnoea, the presence of a growth may be occasionally inferred, by the experienced laryngologist; but those who have not met with many laryngeal polypi would be rash to form a diagnosis from functional symptoms. It must not be forgotten, however, 1 This arrangement of the symptomatology, I have modified from Dr. Causit's most valuable work, already referred to. It appears to me to be preferable to the divisions of symptoms into subjective and objective, which I formerly employed. Symptoms.—Modification of Voice. 19 that many years before the laryngoscope was invented, both Brauers and Ehrmann l were able to diagnose growths with such accuracy, that they felt justified in opening the thyroid cartilage. In Brauers' case, the use of the actual cautery brought on hectic fever, but Ehrmann's skilful diagnosis and bold treatment, as is well known, were crowned with success. Modification of the Voice.—An alteration in the voice is the most constantly present, though not invariable, symptom of a growth in the larynx. Out of my 100 tabulated cases, the voice was impaired 90 times; there being complete loss of voice in 55 cases, and hoarseness in 37 cases. Of the 55 cases in which there was com- plete aphonia, this was the only symptom 35 times, other symptoms being also present in the remaining 20 cases; whilst of the 2>7 cases in which dysphonia occurred, the alteration of voice was the only symptom 17 times. It will be seen, therefore, that impairment of the voice was the unique symptom in no less than 52 per cent, of my cases. Aphonia or modification of the voice was present in 92 of the 171 cases in Table D in which the symptoms were stated, that is, in 53*8 per cent, of the cases. There is a kind of dysphonia which, when present, is very characteristic of growth-cases. The patient whilst speaking in his natural voice, or in a slightly hoarse or croupy tone, suddenly becomes completely aphonic, and again, after a minute or two, recovers his hoarse or natural voice.2 The only kind of dysphonia which at all resembles this, is found in a form of nervo-muscular disease of the larynx, in which the tensors of the vocal cords are spasmodically affected. The constant straining character of the voice in these latter cases, however, at once differentiates them from all others. In the history of these cases we generally find that dys- phonia precedes complete loss of voice ; but, as the growths 1 Op. cit., Observations, Cases xv. xxix. 2 Krishaber (Op. cit.) has applied the term vocal asynergy to the loss of power of control over the voice, which is so often present, and indeed one of the first symptoms of a growth in the larynx. As, however, asynergy is a term implying a want of correlation, dependent on impaired nervo-muscular power, it is evi- dently incorrect to apply the word, in cases where the absence of correlation is due to direct mechanical causes. 20 On Growths in the Larynx. originate in hyperaemia, the early hoarseness may, in some cases, be due to that condition. Sometimes the growth does not impair the ordinary speaking voice, but entirely destroys many of the notes in singing,1 and in the case of vocalists the hoarseness is sometimes also preceded by a want of power and of control in the higher notes.2 In some cases the natural voice of the patient is thick, but he is able to speak in a clear falsetto voice. A double-toned vocalization, in which (secondary) falsetto sounds are heard simultaneously with the ordinary, though impure, voice, has been described by Tiirck as Diphthonia.3 The modus operandi of these growths is manifold : some- times by their situation on the vocal cords, they directly modify the vibration of the cords ; sometimes, by their pressure on the ventricular bands, they interfere with the 1 Appendix A, Cases 26, 39, and 77. 2 Ibid., Case 93. 3 Dr. Tiirck relates, amongst others, the case (Case 206, Op. cit.) of a man, aged 44, who had small growths on both vocal cords :—" The chest voice was very hoarse, and his intonation very impure. His ordinary speaking voice __-m-_ reached from f to c, but he could go down as low as c below ==rP^=r— the line. In loud vocalization and loud speaking, the first a above the line sounded simultaneously as a falsetto. In the lower (chest) notes, the associated falsetto note (a above the line) was more often present than in the higher notes. In all the various notes which he could produce, the high falsetto note remained entirely unaltered ; in phonetic in- spiration there was no double tone." Merkel (Anatomy and Physiology of the Human Vocal Organs, Leipzig, 1857, p. 628, quoted by Tiirck, Op. cit., p. 473) observes that "when the voice is, so to speak, slightly veiled, a little mucus having remained in the larynx, between the vocal cords and ventricular bands, if one tries to pass from a clear high falsetto gradually down, it often happens that these tones sound impurely. In my own case, it occurs most frequently, when b has been the fullest and loudest falsetto tone (sometimes it is b flat or a), that the next three tones, a, g, and/, show this impurity; that is to say, they are accompanied by an intervening sound or jarring incidental tone, which, as a rule, is exactly an octave lower than the principal tone. On one occasion, the incidental tone was almost as loud and distinct as the principal tone, so that I could sing a whole passage in the right octaves, although they did not sound quite harmonious. This phenomenon was seldom shown in more than three consecutive tones. It is true that it sometimes happens that the impure incidental tone belongs to another scale, but this is more rare." The vocal phenomena, here described by Merkel, as occasionally resulting from the accidental lodgment of mucus in the neighbourhood of the vocal cords occur as a more permanent condition when produced by a growth. Symptoms.— Cough. 21 motion of air in the ventricular cavities ; sometimes, when broadly attached, and projecting into the centre of the laryngeal canal, they prevent the vocal cords being thrown into vibration by the expired current of air ; and sometimes they directly interfere with the approximation of the cords. Growths situated near the centre (of the antero-posterior diameter) of the vocal cords alter the voice, cceteris paribus, to a greater extent than those attached at the extremities ; but those actually springing from the anterior commissure, by preventing the approximation of the cords, obliterate the voice even more promptly and completely. As has been remarked by Czermak, a small growth often interferes with vocalization more than a large one; for the small neoplasm, which is almost always sessile, greatly modifies the vibration of the vocal cord to which it is attached, whilst a large one may become pedunculated as it grows, and by rising up into the cavity of the larynx, may interfere very little with the normal formation of sound. Growths on the epiglottis and ary-epiglottic folds do not generally affect the voice, unless they attain a very large size; and small neoplasms on the ventricular bands do not always cause dysphonia. Growths below the vocal cords, by diminishing the column of air passing through the larynx, or by being forced up into the glottis in expiration, often cause aphonia. Cough.—Patients with laryngeal growths do not, as a rule, suffer much from cough ; but, occasionally, on the other hand, this symptom is so severe as to cause very great incon- venience, and it may even give rise to haemoptysis. In Dr. Causit's 46 cases of laryngeal growths, 26 of the patients suffered from cough; but, in my 100 cases this symptom was troublesome in'only 12 instances. In Ap- pendix D there are 171 cases in which the symptoms are stated, and in 27 cough was present, that is, in 1578 per cent. The character of the cough depends upon the size and situation of the growth ; it is generally dry and hacking, and often aphonic. In young children or in adults, when the growth is very large and situated in the neighbourhood of the glottis, it has often a croupy character. In 7 out of On Groivths in the Larynx. the 26 cases noticed by Dr. Causit, it was described as "croupal." I have seen it occur also in two cases in violent paroxysms. Dyspnoea.—Dyspnoea was present 30 times in my 100 cases, and was serious or threatened suffocation in 15 cases. Difficulty of breathing occurred in about the same per- centage of the cases I have collected in Appendix D. Most of the specimens of laryngeal growths in the metropolitan museums were taken from patients who died from suffoca- tion ; and in nearly all the cases reported in the medical journals before the invention of the laryngoscope, dys- pnoea was a prominent symptom. The dyspnoea is often paroxysmal. The explanation of this circumstance, as in many other cases of laryngeal obstruction, is, that the patient is able to breathe well, even through a narrowed windpipe, provided that no further diminution suddenly occurs. If, however, the patient takes cold, and the mucous membrane becomes a little swollen, a paroxysm of dyspnoea may supervene. In the same manner, if the respiration be hurried by exertion, an attack is likely to come on. Dyspnoea likewise sometimes occurs suddenly, from the patient getting into an unusual position, and from the growth being consequently thrown more across the glottis. In one of my cases1 the patient could only sleep with the hand resting under the neck; and if by chance her head slipped away during sleep, she immediately woke with a severe attack of dyspnoea. As has been pointed out by Dr. Causit, in analyzing his collected cases, the attacks of suffocation most frequently occur in the evening and during the night. This circum- stance, however, rather increases than diminishes the diffi- culty of estimating the value of the symptom in diagnosis, as in almost all affections attended with dyspnoea, exacerba- tions take place at night. The stridulous character of the dyspnoea differentiates it, however, from the various forms of asthma. The result of my experience enables me to entirely endorse the correctness of Dr. Causit's observations, as to 1 Appendix A, Case 84. Symptoms.—Pain. 23 the mode in which the paroxyms occur :—" The attacks of suffocation are, in general, rare at the commencement, but as the disease advances they increase in intensity and frequency. The intervals are at first very long (from some weeks to months, or years), but they gradually shorten, so that the attacks become very numerous and very intense." As a rule, the amount of dyspnoea depends on the situation of the growth and on the relation of its size to that of the laryngeal canal; but this is not invariably the case: in one case1 that has come under my notice, a subglottic growth of moderate dimensions caused extreme dyspnoea by preventing the abductive movement of the vocal cords, and some of the largest growths which I have met with have caused but little embarrassment in the breathing; whilst small excrescences sometimes give rise to violent spasm or persistent dyspnoea.2 It almost invariably happens, that inspiration is much more difficult than expiration, and Lewin3 has remarked, that the character of the respiration has a certain diagnostic value, as regards the seat of the growth. When inspiration is noisy and stridulous, and expiration comparatively easy, the growth is probably situated above the vocal cords, and vice versa. Pain.—According to my own experience, actual pain is seldom caused by growths in or about the larynx, but uneasy sensations are occasionally felt. In only one of my 100 cases4 was there actual pain, and in one5 there was a sensation of oppression. In the foreign tables,6 however, pain 7 is stated to have occurred in no less than 9 cases ; 7 patients experienced the sensation of a foreign body in the larynx, and in 3 cases there was a feeling of op- pression. Though, however, patients rarely complain of the feeling of a foreign body, they frequently have a disposition 1 Appendix A, Case 81. * Appendix A, Cases 21 and 60. 3 Deutsche Klinik, 1862. 4 Appendix A, Case 97. 5 Appendix A, Case 90. 6 Appendix D. 7 Although I have endeavoured to exclude all cases of cancer from Appendix D, it is possible that some malignant cases have been accidentally inserted. If this has occurred, it will account for the greater frequency of pain in the cases of other practitioners than in my own cases. 24 On Groivths in the Larynx. to clear the throat, as if to expel some accumulated mucus. I have most commonly met with this symptom in cases of pedunculated growths, especially when they were attached to the vocal cords. In one case,1 in which there was a growth the size of a pea on the cartilaginous portion of the right vocal cord, the only symptom complained of was a sensation " of a constant tickling in the throat;" and the same sensation was experienced in another case, in which the growth was situated in the hyoid fossa.2 In one case, in Appendix D, there was simply a tickling sensation in the larynx, and in another, great irritability of the palate. Dysphagia.—Difficulty of swallowing does not generally occur, except where the growth springs from the epiglottis or where it attains a very large size ; it is occasionally present, however, when the neoplasm arises from the arytenoid cartilages. In my ioo cases here tabulated (Appendix C), dysphagia was only present 8 times, and in each of them, with perhaps one exception,3 the epiglottis was the seat of the disease. In the exceptional case re- ferred to, there was difficulty in ascertaining the exact origin of the growth : it was thought to spring from the ventri- cular band ; but in all probability the epiglottis was also involved. In one case only4 was there odynphagia,5 i. e. pain in swalloiving. Physical Signs. The physical signs are much more important than those of a functional character; and amongst them those observed with the laryngeal mirror stand pre-eminent. 1 Appendix A, Case 13. 2 Appendix A, Case 89. » Appendix A, Case 83. * Appendix A, Case 28. 5 Impaired deglutition may be due to difficulty of swallowing, or pain in swallowing: both these symptoms are commonly known under the name of dysphagia (Svq, difficulty), which term should be limited to those cases in which there is obstruction or loss of power. Where, however, impaired deglutition is the result of pain, odynphagia (oSvvt], pain) would be more correct. This is not a pedantic technicality, as deductions, drawn from the use of one or other of these terms, would entirely depend on which term were employed. Symptoms.—Laryngoscopic Signs. 25 Laryngoscopic Signs)—So complete is the information furnished by the laryngoscope, that were it not that there are certain rare and exceptional cases in which this instru- ment cannot be employed, the general semeiology would be useless. The situation of the growth can almost always be ascertained with the mirror, but in a few cases, where the growth is very large, the exact seat of origin may be concealed. The following table shows the parts most frequently affected in my 100 (treated) cases :— Both vocal cords 27 Right vocal cord . . .' 25 Left vocal cord 14 Vocal cords and ventricular bands 2 Vocal cords and epiglottis 4 Epiglottis ..... 8 Epiglottis and ventricular band 1 One or both ventricular bands . 6 Posterior wall of larynx . 7 Whole surface of larynx . 3 Capitulum Santorini . 1 Inter-arytenoid fold . 1 Hyoid fossa .... 1 It is thus seen that the vocal cords are especially liable to be affected, these parts having been alone attacked in 74 cases, and suffering in conjunction with other parts in no less than 85 cases. Of the cases in Appendix D, in which the situation is stated, the vocal cords were alone affected in 61*4 per cent., and in conjunction with other parts of the larynx, in 64-4 per cent. On the other hand, it will be seen the arytenoid cartilages, with their folds of mucous mem- brane and secondary cartilages, enjoy great immunity. The laryngoscopic appearance can best be described in detail, by separating the different kinds of tumours, according to their pathological nature. Papillomata.—Papillary growths are generally sessile, 1 Under this head, the form, colour, size, and situation of the various growths will be considered; the information as regards structure will be found in the section on Pathology. 4 26 On Gi'owths in the Larynx. though occasionally pedunculated. They are often multi- ple, and sometimes occur symmetrically.1 They vary in size, from a grain of mustard to a walnut, but they do not often attain the latter dimension. Their most common size is that of a large split pea. These growths may have a mammillary, cauliflower, raspberry, foliated, fimbriated, den- tated, or vermiform configuration. They are generally of a pink colour, but they may be white, or even bright red, as will be seen by reference to Plate II. figs. I, 2, 3, 5, 7, and 11. In no less than 42 of my 6j cases of Papilloma, the disease was confined to the cords, and in 6 instances the vocal cords were affected in common with other parts of the larynx. It will thus be seen that the vocal cords were implicated in more than 70 per cent, of the cases of Papil- loma. Of the 42 cases in which the vocal cords were alone affected, the right cord was 16 times the site, the left 7 times, and both cords 19 times. Benign Epithelial Growths.—Benign epithelial growths (Plate V. fig. 1) are generally sessile, and vary in size from a split tare to a sparrow's egg. Their surface is generally smooth, but they may be furrowed or even lobulated. They are commonly white or pale red. They are most frequently seen upon, or very near, the vocal cords. Fibromata.—True fibromata (Plate II. fig. 4, and Plate III. fig. 10) are usually round or oval, but occasionally are of a very divided form, not unlike cauliflower excrescences,2 and are generally, but not invariably, pedunculated. Their surface is usually smooth, but it may be rough, irregular or wavy. They are commonly of rather a bright red colour. They are almost always single, and vary in size from a split pea to an acorn. Rokitansky,3 however, has reported one case, in which the growth was as large as a pigeon's egg. These growths, like the papillary tumours, occur most frequently on the vocal cords. In 5 of the 11 cases now given, the cords were the sole seat of the neoplasm. Fibro-ccllular Growths.—Fibro-cellular tumours (Plate II. ' 1 Appendix A, Cases 40 and 80. 8 Appendix A, Cases 78 and 97. 3 Op. cit. Symptoms.—Laryngoscopic Signs. 27 fig. 10) are almost invariably pedunculated, and of a round, or pyriform, contour. The colour may be either pink, or bright red, and the surface is generally smooth. Unlike mucous polypi of the nose, these growths are generally single. In one case l the growth was as large as a cherry, but the others were very small pyriform tumours. In 2 cases, the growths were attached to the epiglottis, and in the 3 others to the vocal cords. Myxomata.—These growths are very rare. In the single case2 (Plate III. fig. 11) which I have met with, the neoplasm grew from the right vocal cord, and was only in part of a mucous character ; this portion was seen with the laryn- goscope to be quite transparent and of a bright pink colour. In a case reported by Dr. Bruns, the growth which, like mine, was on the right vocal cord, was about the size of a filbert slightly lobulated, of pale pink colour, and smooth surface; before removal it was regarded as a "soft fibroma." Lipomata.— No case of lipoma has come under my own observation, but Professor Bruns 3 has met with one instance. The growth, which was very large, obscurely lobulated, and of a bright red colour, sprang from the mucous membrane covering the left arytenoid cartilage, and occupied almost the entire larynx from before backwards, as wrell as from side to side. The examination of the growth enabled Dr. Bruns to diagnose its nature whilst it was still in situ. It was ascertained to be soft and elastic; the laryngeal sound could be easily pressed into the tumour, and on withdrawing it, the impress of the sound immediately disappeared. Fasciculated Sarcomata (Plate III. figs. 3, 7, and 8).—There is nothing distinctive in the appearance of these growths. They are sometimes rough and sometimes smooth, sometimes white and sometimes pink or red. In one of my cases the growth sprang from the vocal cord, in another, from the anterior commissure, and in a third, from the ventricular band. In 4 of the 6 foreign cases, the growth was situated in the neighbourhood of the vocal cords, and in the remaining two the disease was general. 1 Appendix A, Case 52. 2 Appendix A, Case 99.' J Appendix D, Case 156. 28 On Grozvths in the Larynx. Cystic Growths.—Cystic tumours (Plate II. fig- 6, and Plate III. figs. I and 2) are round, egg-like projections, and as they usually give rise to some local irritation, they are themselves red, and are surrounded by a hyperaemic area. In one of the cases 1 hereafter reported, the growth was the size of a sparrow's egg; in the other2' it was as large as a cherry. In both my cases, as well as in one recorded by Mr. Durham,3 the tumours grew from the epiglottis ; but cystic growths, springing from the ventricle, have been re- ported by Gibb,4 Bruns,5 and others. Adenomata.—There is nothing characteristic in the appear- ance of glandular tumours in the larynx. In one of my cases, situated below the anterior commissure of the vocal cords, the growth looked like an ordinary cauliflower excrescence, and in the other the tumour, which grew from the epiglottis, was large and nodulated, and had very much the appearance of an hypertrophied tonsil (Plate III. figs. 4, 5, and 6). In both cases, the growth was of pink colour. Angeiomata.—The only case of vascular growth5 (Plate II. fig. 12) which has come under my notice, was of a black- berry-like appearance, in colour, form, and, size, and grew in the right hyoid fossa. Laryngeal Sounds and Crotchets.—By means of the laryn- geal sound or probe, the density, the size, and the exact origin of a growth may often be determined, when with the laryngeal mirror alone there is still doubt as to these various points. A smooth growth may be either a fibroma or a lipoma; but whilst the former does not yield to pressure, the fatty growth is soft and resilient. The appearance of a laryngeal growth in the mirror is often deceptive, and it is often only by moving it with the sound, that its dimensions can be at all accurately determined. This is more especially the case, because, of course, only one surface of the tumour is visible in the mirror. Again, the insertion of a growth is sometimes 1 Appendix A, Case 25. * Appendix A, Case 85. 3 Medico-Chirnrgical Transactions, 1863 ; and Appendix D, Case 55. 4 Appendix 1), Case 57. " Appendix D, Case 84. s' Appendix A, Case 89. Firr. i.—Laryngeal Sounds and Crotchets. A. Common Laryngeal Sound, especially useful for testing the resiliency of growths. P. Laryngeal Sound, for introducing between a growth and the wall of the larynx. C and D. Crotchets, for gently hooking a growth, and thus ascertaining its attachment, when its origin is hidden. 30 On Growths in the Larynx. hidden by the growth itself, and it is only by traction with the crotchet that the precise origin can be ascertained. The various kinds of sounds and crotchets which I am in the habit of employing are shown in Fig. I. Digital Exploration.— Examination with the index-finger is of some value, in those cases, where the growth is situated on the epiglottis, or the ary-epiglottic folds; but it is seldom of any practical service, where the tumour is attached at a lower level. By means of this method, evidence can sometimes be obtained, as to the density and mode of insertion of the growth. In young children, the finger can, indeed, be passed down as far as the vocal cords; but, as in these subjects, the growths are generally of extremely soft, papillomatous cha- racter, they cannot, unless large, be detected with the finger. It is important to bear in mind, that in these young patients, before the cornua of the hyoid bone are developed, the body of the bone feels, on introduction of the finger, very much like a hard growth, and I have reported one such case1 in which a mistake actually occurred. In this instance, a growth was present; but on digital examination, the body of the hyoid bone was mistaken for it, and the growth itself was not felt. Forced External Elevation of the Larynx.—By pressing the larynx upwards with the hand on the thyroid cartilage, and by pulling the tongue out, the upper orifice of the larynx may occasionally be seen. In this way, growths in the upper part of the larynx are sometimes visible. Voltolinic recom- mends that in addition to external manipulation, and holding out the tongue, the fauces should be slightly irritated, so as to produce moderate retching. By adopting this procedure, he was enabled to demonstrate a growth on the posterior wall of the pharynx just at the orifice of the oesophagus, to Professor Middeldorpf, who succeeded in removing the tumour with a galvanic cautery loop, and (though an accurate diagno- sis was first made with the laryngoscope) in carrying out the 1 Appendix B, Case 3. 2 Separat-Ahdruck aus der Berlin. Klinik. Wochcnschr., 1868, No. 2^. Symptoms.—Auscultation of the Larynx. 31 treatment the laryngeal mirror was not used. Other cases' have occurred, where large growths in this situation, have been seen projecting into the pharynx, when the mouth was widely opened, without any external manipulation of the larynx. Auscultation and Percussion of the Larynx.—On ausculta- tion of the larynx when the growths are at all large, moist sibilant rales may be sometimes heard, but they are only characteristic of laryngeal obstruction. On this subject, Riihle2 remarks, "that in pedunculated tumours of the larynx an auscultatory phenomenon, a valvular murmur is sometimes heard, which, by the exclusion of the accidental impaction of a foreign body, and by its repeated occurrence during a considerable length of time, has undoubtedly a certain value." Undue importance has been attached to this valvular sound, which took its origin in Ehrmann's cele- brated case,3 in which the patient, by a sudden inspiration and expiration, "was able to imitate the sound of a valve alternately opening and shutting." This phenomenon, which was quite accidental, could be produced by a voluntary effort on the part of the patient. When the larynx is blocked up with growths, dull sounds are elicited on percussion. Small growths, however, do not in any way modify the usual resonance. Microscopical Examination.—It occasionally happens, espe- cially in papillomatous growths, that small particles are expectorated, and, on microscopical examination, their nature can be verified. When this occurs in conjunction with other symptoms, it of course furnishes general evidence as to the nature of the disease ; and when there is aphonia at the same time, it may be inferred that the growth is in the neighbour- hood of the vocal cords. This evidence of the presence of growths is, however, so rarely present, that it must be 1 Polypi of the Larynx, by Dr. Horace Green. New York, 1852, p. 62. Also Rayer, Maladies de la Peau, torn. ii. p. 422. 2 Op. cit., p. 223. 3 Op. cit., Observations, xxix. p. 23. 32 On Growths in the Larynx. regarded more as an accidental phenomenon, than a sign of the disease. These remarks on the microscopic investiga- tion of growths only apply to the examination of particles accidentally expectorated. The histological differences of the various laryngeal growths are described in detail, in the section on Pathology. Constitutional Condition.—In the early stages, the disease is purely local; but if the growth become large, it may, by embarrassing the respiration, or through other causes, give rise to constitutional disturbances ; in this way, some amount of wasting and hectic may be caused, so that these cases were formerly mistaken for phthisis. Marked constitutional symptoms are, however, of exceedingly rare occurrence. Course and Termination.—The various symptoms already described generally develop themselves slowly, taking many months for their evolution. There is always a difficulty, however, in fixing upon the commencement of the disease, because the hyperaemia, which generally precedes the growth of a tumour, gives rise to the same phenomena as the neo- plasm itself. The progress of the case depends, of course, in a great measure, on the pathological nature of the neo- plasm. In four instances,1 however, out of my ioo treated cases, I think the date of origin may be at least limited to within a certain period. In one case, a growth which blocked up the entire larynx was certainly of not more than six months' duration ; in the second case, two months previous to the discovery of a growth, the size of a pea, on each vocal cord, I had examined the larynx, and had noticed only conges- tion of the mucous membrane of the cords ; in the third case a very large growth was seen after an interval of nine months from the date at which the patient had left my carer just recovered from a sharp attack of laryngitis ; in the fourth case the patient left me with only slight thickening and a tendency to ulceration of the epiglottis, on November 6th, 1869, and within two months, returned with a growth the size of a large cherry. 1 Appendix A, Cases 63, 80, 86, and 88. Course and Complications. 33 After attaining a moderate degree of intensity, the symptoms often remain stationary, and it is surprising how long patients—especially those among the lower classes— suffer from aphonia before they seek relief. In one of my cases the patient had suffered from aphonia for 24 years, and another from dysphonia for 23 years. Dyspnoea, however, is a much more serious and a more progressive symptom, and after a few months, the patient is obliged to apply for medical aid. Dysphagia also, being a constant source of annoyance, quickly leads the sufferer to seek relief. If the growth con- tinue to increase, and be not checked by treatment, the case is likely to end in suffocation. The termination of the disease is more fully considered under the head of Prognosis. As a curious fact recorded in medical literature, rather than a practical matter bearing on the course of laryngeal growths, it may be remarked, that there are a few instances in which the disease has been cured spontaneously. In one of these, briefly referred to by Causit,1 the polypus was expelled by coughing. In another case, reported by Dr. Dobie,2 a pedunculated growth, about the size of a small cherry, attached to the epiglottis, separated spontaneously. Tiirck 3 also relates a case, in which this fortunate termination took place as the result of acute laryngitis. Complications.—Complications are fortunately rare in the natural history of laryngeal growths. The disease being undoubtedly of local character, complications which arise, are principally due to mechanical causes. Spasm of the glottis is essentially a direct consequence of a growth, but oedema of the glottis, which is only an occasional concurrent, may fairly be regarded as a complication. Krishaber4 remarks that in one autopsy he found considerable pulmonary emphysema, and cardiac hypertrophy. 1 Op. cit., p. 33. 2 American Monthly Journal of Medical Science, 1853. 3 Tiirck, Klinik der Krankheiten des Kehlkopfes, p. 305. Wien, 1866, p. 305. 4 Ot>. cit., p. 749. 5 ( 34 ) SECTION IV. DIAGNOSIS. Growths in the larynx cannot well be mistaken for any other disease, if a laryngoscopic examination be possible. Eversion of the Ventricle is, perhaps, the only intelligible source of error, and this condition is probably rare. I know of only two specimens; one of these was exhibited by Dr. Moxon, at the Pathological Society ;x the other is in the museum of the Hospital for Diseases of the Throat. Dr. Moxon's specimen was removed from the body of a man who died in Guy's Hospital from cancer of the stomach. Dr. Moxon had often spoken to the patient, whose " voice was always such as not to attract attention? After death, a tumour was found hanging down over one of the vocal cords. It was semi-elliptical in shape, and was rooted above in the anterior half of the ventricle of the larynx. The tumour " could be easily put up into the usual position of the sacculus laryngis ; that when so placed—the tumour inverted, and returned behind the false vocal cord—it appeared as the sacculus laryngis, while, without it, there was no sacculus laryngis ; so that there could be no doubt that it was an everted sacculus." My specimen was taken from a patient who had been admitted into the Hospital on the night previous to his death, in a very debilitated condition; no notes were taken, and there is therefore no record as to the state of the voice. After death, the left ventricle of the larynx was found to be entirely everted, and the right sacculus protruded slightly from the 1 Transactions of the Pathological Society, vol. xix. p. 65. The specimen is also described and figured by Mr. Durham (Op. cit., p. 580). Differential Diagnosis. 35 ventricular orifice. The appearance is shown in Plate V. fig. 2. On carefully sawing out a portion of the left ala of the thyroid cartilage from without, it was seen that there was no sacculus laryngis on the left side ; but on return- ing the protruded sac, the well-known appearance of the Phrygian cap was presented to view, and the anatomical aspect of the larynx on this side became perfectly normal. The mucous membrane of the larynx was seen to be covered with superficial ulcers : the destructive process appeared to have principally affected the glandulse, and was most marked on the ventricular bands, and the cushion of the epiglottis. There were cavities in both lungs. In Dr. Moxon's case, there is every reason* to believe that the prolapse took place in articulo mortis, and it is quite possible that such may have been the case in my own specimen. Dr. Moxon remarks that this condition would " be very tempting to one skilled in the removal of laryngeal polypi," and indeed, if eversion took place during life, I know of no other treatment but excision of the sac which would relieve the symptoms. The diseased conditions which might be mistaken for growths, are those occurring in syphilis and laryngeal phthisis ; but independently of their commemorative signs, these diseases are easily differentiated by means of the laryngeal mirror. Elephantiasis is so rare in this country, that it only requires a passing word, and in lupus, loss rather than increase of substance is the distinguishing feature. It is, how- ever, more important to point out the differences of malignant tumours and outgrowths. Syphilis.—The condylomata of syphilis are seen as irregular, whitish, very slightly raised, prominences on the congested membrane, the posterior wall of the larynx being their most common site. These formations are comparatively rare, and when present, generally occur from six weeks to three months after the primary inoculation. -They soon disappear under the use of mineral astringents, or other remedies which modify the nutrition of the part, and, even if left to their natural course, they quickly subside. 36 On Growths in the Larynx. False Excrescences are the result of syphilitic ulceration and subsequent cicatrization, and occur as irregular projections in different parts of the larynx. Though seldom, in themselves, causing dyspnoea, this symptom may result from the nar- rowing and distortion of the windpipe, which takes place from the accompanying cicatricial contractions. False ex- crescences are often accompanied by dysphonia or complete loss of voice ; but though their removal sometimes gives considerable relief, it does not generally restore the vocal function, owing to the associated pathological conditions already referred to. The large roundish gummata, which are occasionally found in the larynx, are so closely incorporated with the adjacent tissues, that they are not likely to be mistaken for true laryngeal growths. Elephantiasis.— In the few cases of elephantiasis that have come under my notice, in which the larynx was affected, the mucous membrane covering the epiglottis was uniformly swollen.1 I believe that the disease never attacks the mucous membrane until after it has shown itself on the tegumentary surface. Lupus.—The thickening of lupus is generally very much like that which occurs in tertiary syphilis, and is usually soon followed by destructive ulceration. Laryngeal Phthisis.—The thickening of laryngeal phthisis has not the defined character of a true laryngeal growth, and is generally soon followed by ulceration. Malignant Growths.—It is not always easy to distinguish between benign and malignant laryngeal growths ; the latter, however, are diagnosed by being thoroughly blended with the surrounding tissues, by being very frequently ulcerated, and by the constitutional history and symptoms of the patient. In these cases, should particles be expectorated, or removed during life, with the aid of the laryngoscope, the microscope cannot be relied on for differential diagnosis. ' In the case of a patient kindly brought under my notice by Mr. Erasmus Wilson in 1865, though there were numerous shining tubercles on the face and other parts, in the larynx there was only thickening of the epiglottis. Differential Diagnosis. 3 Several cases have come under my notice where the histo- logical features were decidedly those of cancer, whilst the clinical history was of a totally opposite character, and vice versa. Outgrowths,1 whether of cartilaginous or fibrous character, are not likely to lead to mistaken diagnosis. It is true that the symptoms are often similar, but when the laryngoscope is used, the entire absence of demarcation between the protuberance and the normal tissues, is at once evident. When seen with the laryngeal mirror, they appear rather as swellings or infiltrations, (though of course present no signs of hyperaemia, nor disposition to degeneration or decay,) than as defined tumours. A case of this sort is contained in my Jacksonian Prize Essay," in which the outgrowth was probably of fibrous character, and Virchow's remarks on cartilaginous outgrowths will be found in the section on Pathology of this treatise. 1 Strictly speaking, of course, the greater number of laryngeal growths are "outgrowths," that is to say, "they are connected with the adjacent parts by continuity of similar tissue, and thus are growths, not in, but of, the parts." The distinctions, however, between growths, or " discontinuous hypertrophies," and " outgrowths," as Mr. Paget has well pointed out, vanish in certain positions, and in the larynx, though nearly all growths are outgrowths, as a matter of con- venience, the term is limited in this article to those cases in which the tumours spring from the deeper tissues. 2 MSS. and Coloured Drawing in the Library of the Royal College of Surgeons. ( 33 ) S K CTION V. PATHOLOGY.1 General Remarks on Pathology.—The investigation into the histology of laryngeal tumours is attended with considerable difficulty, for they are frequently removed in fragments, and even when the whole growth is taken away at a single operation, its origin is often so much lacerated, that it is impossible to tell whether such a neoplasm is a mere out- growth or whether it is a true tumour. Again, inasmuch as these growths are often removed piecemeal, an opinion as to the pathological nature of the growth is apt to be formed after the examination of any one fragment removed. Virchow2 has already called attention to the frequent mistakes which occur from the examination of small portions of tumours, even when removed in their entirety, on account of their structure differing so much in different parts ; and it will be at once evident that such sources of error are exceedingly likely to arise when a growth is removed in several particles at different times. The various growths found in the larynx appear to be due to perverted develop- ment of either the connective tissue or its superjacent structure (the epithelium), or of the parts contained in the connective tissue (the glandulae and vessels). The fibro- 1 The situation, size, and external appearance of the various kinds of laryngeal growths having been described under the head of Symptoms (Section III., Laryngoscopic Signs), it has not been thought necessary to repeat them in this chapter. It may here be observed, that Appendix D, containing the tabular statement of all cases treated by other practitioners, has been of little use in forming an estimate as to the frequency and situation of different kinds of growths, owing to the information on these points being very incomplete. 2 Op. cit., vol. i. p. 348. Pathology. -^Papillomata. 39 cellular growths constitute perhaps the type of the connective- tissue tumours, whilst fibromata represent those in which the fibrous tissue predominates; myxomta, those in which the mucous or embryonic matter is most abundant; fasciculated sarcomata, those in which " the embryonic tissue has already undergone a trace of organization and evolution in the direction of connective tissue ;" and lipomata, those in which fatty matter is very abundant. The epithelium being more exposed, is even more subject to perverted development than the connective tissue ; we have, therefore, simple epithelial growths ; or when, as is commonly the case, they assume a papillary structure, papillomata are formed. From the abnormal evolution of the glandular elements, we have cystic growths and adenomata, whilst the morbid production of blood-vessels gives rise to vascular grozuths, or angeiomata. Papillomata are by far the most frequent of all the benign growths in the larynx. In my ioo tabulated cases, 67 were judged to be of this character.1 These growths occur at an earlier period of life than the other kinds of tumours, nearly all cases found in the first decennial period being either papillomatous or benign epithelial. In the cases of congenital growth collected by Dr. Causit,£ and in those now reported by myself, the neo- plasms have, when examined, generally been found to be of a warty character. The (supposed) congenital tumours in the Museums of St. Bartholomew's3 and St. Thomas's Hopitals 4 are likewise of a warty structure. The rate of growth in this class of tumours varies greatly, but it is generally most rapid at the inception. In one 1 A microscopic examination was made in 29 instances. In Appendices A and B, where the microscope was not used, and the nature of the growth was merely inferred, the pathological chaiacter is bracketed at the heading of each case; thus, "(Papillomatous) Growth on Right Vocal Cord," &c, means that the growth was inferred to be papillomatous ; but where the adjective is written without brackets, a microscopical examination will be found accompanying the description of the case. 8 Op. cit. 3 Series XXV. No. 17. 4 Series IV. No. 52. 40 On Growths in the Larynx. instance,1 two growths, placed symmetrically on the posterior part of the vocal cords, attained the size of split peas in less than three months ; and in another2 the growth reached the size of a raspberry in less than nine months. Papillomata are classified by some pathologists, and notably by Rokitansky and Virchow, under the head of Fibromata ; but inasmuch as the fibrous element is generally very sparingly developed, and frequently not to be dis- cerned, this arrangement does not appear to me to be justifiable. Mr. Paget3 observes, that these growths " may be occa- sioned either by an hypertrophy of normal papillae, or may be entirely new formations in the part. In their general form and arrangement they have many points of resem- blance, but on an enlarged scale, to the papillae which, in various localities, constitute natural projections from free surfaces; more especially from the skin and mucous membranes. To some extent these papillary growths, in whatever locality they may be found, correspond in structure with each other. Their basis substance is formed of con- nective tissue, which is continuous with that which normally exists in the part; whilst the free surface is covered by an epithelium, which may vary in its thickness, and in the number of its layers, according to the seat of the tumour. Blood- vessels, and even nerves, enter into the interior of the papillae. When a number of these new. papillary growths become aggregated together, they may form a tumour of some size. Of the cutaneous papillary growths, the best-known example is the common wart, which in many persons forms in such numbers on the skin of the hands. These warts consist in an excessive development in length and thickness of both the dermal and epidermal structures which con- stitute the papillae of the skin. The condylomatous growths which sometimes form in the region of the prepuce, and about the labia and anus, are excessive developments of 1 Appendix A, Case 80. 2 Appendix A, Case 86. 3 Lectures on Surgical Pathology, third edition, 1870, edited by Professor Turner, M.B., p. 591. Pathology.—Papillomata. 41 the same character; and when they exhibit a very irregular, subdivided surface, they present the well-known cauliflower appearance .... Various of the mucous membranes are also liable to be affected with abnormal papillary growths. Many of the mucous polypi are complicated with papillary formations. Sometimes the new-formed papillae are scattered irregularly over a considerable tract of the mucous surface, so as to give it a villous, velvety appearance, though at others they are aggregated into the form of a distinct tumour .... The papillae are recognizable to the naked eye, and impart a distinct villous appearance to the mucous surface, from which they spring. They divide and give off lateral sprouts or branches; they are vascular, and the epithelium which invests them usually corresponds in form with the normal epithelium of the part." This last observation does not hold good with regard to the larynx, for the laryngeal neo- plasms have generally a tesselated epithelium, even when removed from parts possessing a ciliated epithelium. My experience on this point is quite in accordance with the observation of Cornil.1 The varied character of the component parts of papillary growths, as well as the various stages of their development and degeneration, were seen in many of the specimens kindly examined for me by Dr. Andrew Clark. One case is described by him as " consisting of more or less perfect connective tissue clothed with many layers of epithelium." In another " enlarged racemose glands were found, the terminal vesicles of which were filled with minute nucleated cells and granular matter." In one case, " the growth was found to consist of two sets of particles; one mem- branous, the others warty or obscurely papilliform. The membranous portion consisted of from twenty to thirty layers of scaly epithelium, surrounded and penetrated by a confervoid growth. The epithelial cells composing the layers were polygonal, flattened, nucleated, and easily affected by weak alkalis and acids. The nucleus of each 1 See Benign Epithelial Growths, p. 46. 6 42 On Growths in the Larynx. cell was oval, abruptly defined, rather large in proportion to the containing cell, in most cases surrounded by a clear halo, and in some showing signs of division. The papillary portions consisted of simple outgrowths of nucleated con- nective tissue, and rudely-formed blood-vessels, clothed with numerous layers of scaly epithelium, similar to those already described. Some of the papillae exhibited large vacuoles, or spaces filled with colloid matter, which, in one or two instances, had burst through the covering epithelium." The microscopic appearance of one of these papillae is well shown in Plate I. fig. I. Foerster1 observes that " the papillary blood-vessel is generally broader than the broadest normal capillary; it is indeed often of colossal size, though its structure is pre- cisely similar to the normal vessel. In many cases, however, the nuclei of the walls are extremely scarce, so that they may, indeed, be altogether overlooked." Virchow remarks,2 "that the papillary formation is not merely an hypertrophy or an excess of normal papillary formation, the pathological papilla being derived from a pre- existing physiological one, but that every free surface can of itself independently develop papillae, even in situations where no papillae previously existed." As regards the mode of development of papillae, he adds, " that the superficial tissues generate, through exuberance, a certain mass, which, as a rule, appears at first as a small round bud, or a small flat elevation of the free surface. As I found a long time ago, after investigations of the external integument and the tunica albuginea of the ovary, the first outgrowths are very small, amorphous, granular, or homogeneous buds, in which cells become evident at a later period. These gradually increase by multiplication of the cells, and by degrees, they develop into large papillae or villi. That which happens on a flat surface can likewise occur in a pre-existing papilla. The papillae can themselves bear 1 Foerster, Handbuch der Allgemein. Pathol. Anatomic Leipzig 18S4 p. 206. 2 Op. cit, p. 334. Pathology.—Papillomata. 43 buds, which may also increase; and thus it may come to pass, in the end, that branch-papillae are formed..... The whole process has the greatest resemblance to that which regularly takes place, on the free surface of the chorion in the human and mammaliferous ovum, and leads to the formation of the fcetal placenta. The villous portion of the chorion is the physiological example of the papillary hyper- plasia, for, to a certain extent, the fcetal placenta may be regarded as a large papillary tumour; and those new forma- tions are analogous, which, corresponding to this description, are formed under morbid conditions on the free surfaces. . . . Many pathologists believe that, in the formation of every warty tumour, the outgrowth of the superficial vessels is the essen- tial element; in other words, that the capillaries of the skin, and especially those of the papillae, widen and lengthen themselves, and gradually push the parts further out. This is decidedly incorrect: equally incorrect for the pathological papillary formation and for that of the villi of the chorion. For if, at all a careful examination is made, it is invariably found that there is a formation of connective tissue, and frequently also of a considerable quantity of epidermic structure, before there is any appearance of vessels, and that vessels are only formed at a later period..... Wherever growth has taken place, an increased forma- tion of granules and cells is found; and the sprouting can often be seen taking place at the extreme points (of the papillae), and it may be observed, that whilst the elements at the base are widely separated, the apex is entirely formed of cells, as I have already proved in the case of the, villi of the chorion.....In some cases the vessels constitute a very considerable bulk of the growth, and it is then often difficult to distinguish the small portion of connective tissue, which forms a kind of investing mem- brane. It sometimes, indeed, happens that the vascular supply is so considerable that it extends throughout, even to the free surface, and the whole outgrowth appears like a vascular plexus. If the growth is enveloped with epi- thelium or epidermis, the epithelial cells are so closely 44 On Growths in the Larynx. applied, that if a single loop be examined, it often ap- pears, as if the epithelium were directly in contact with the capillary wall. When, however, the parts are specially considered, and their mode of development is studied, it is evident that a fine stratum or a kind of adventitious membrane of connective tissue always exists, and that the supposed sprouting out of vessels into the epithelium does not actually occur. If the epithelium be very thin, as it is on mucous membranes, these very broad and thin vessels may, as one can readily understand, be exceedingly exposed." In his desire to include a considerable variety of growths under the head of Fibromata, Virchow1 appears to me to have somewhat stretched a point with reference to the papillary tumours. These growths are certainly epidermal or epithe- lial productions, the areolar tissue being a very unimportant element in their structure. Nevertheless, he remarks that " these growths, whether they contain more or less connective tissue, are in fact of the nature of connective tissue, and must be regarded as outgrowths of pre-existing connective tissue. This character is so apparent, that for a long time they have been described under the name of vegetations. Latterly, an especial value has been attached to the papillary form of growth, and, following Kramer, they have been described under the name of Papillomata. This, however, is quite superfluous, as there are already descriptions enough for individual forms ; it is, moreover, inaccurate, as the nature of the tumour is essentially that of connective tissue in papil- lary form. The generic name must therefore be Fibroma, and the term ' papillary' can only be applied qualitatively." Papillomata show a certain disposition to recurrence, the disease having reappeared in 4 instances out of the 67 cases treated by me. In two others, where the neoplasm was not entirely eradicated, there was rather rapid and con- siderable increase of the remnant. I have seen many of my 1 Virchow, whilst including papillary growths under the head of Fibromata, nevertheless admits that there are some neoplasms (described by him under the term of Acuminated Condylomata) in which "the growth might almost be correctly reckoned amongst epidcrmoidal tumours." Pathology.—Carcinomatous Papillomata. 45 patients at long intervals after they have been cured, but, of course, there remain some who were lost sight of at a com- paratively early period. The proportion of the recurrence is therefore, in all probability, rather greater than my statistics indicate. Relation of Papillomata to Warty Cancer.—Many kinds of neoplasm undergo papillary development ; but it is only epitheliomata that can give rise to difficulty in deciding as to the nature of a growth. Mr. Paget remarks,1 that, in warty cancer, " a certain portion of the skin or mucous membrane is infiltrated with epithelial cancer-structures; on this, as on a base more or less elevated and imbedded, the papillae, variously changed in shape, size, and grouping, are also cancerous; their natural structures, if we except their blood-vessels, which appear enlarged, are replaced by epithelial cancer- cells. And herein is the essential distinction between a simple or common warty or papillary growth, and a can- cerous one, or warty cancer. In the former the papillae retain their natural structures ; however much they may be multiplied or changed in shape and size, they are either merely hypertrophied, or are infiltrated with organized in- flammatory products; however abundant the epidermis or epithelium may be, it only covers and ensheathes them. But in the warty cancer the papillae are themselves cancerous; more or less of their natural shape, or of the manner of their increase, may be traced : but their natural structures are replaced by cancer-structures; the cells, like those of epithelium, lie not only over, but within, them." Although the foregoing description is of much value, I do not think that it is sufficiently precise to enable the microscopist to differentiate accurately between the simple warty, and truly cancerous, neoplasms. The relation of cells is so much a matter of accident, and their form and contents so dependent on their period of development, that the " cancer-structures " of epithelioma do not form a reliable basis for differentia- 1 Op. cit., p. 706. 46 On Growths in the Larynx. tion. It appears to me that the " epidermic globes" of Lebert, or " laminated capsules " of Mr. Paget (Plate I. fig. 8), alone furnish the crucial test. These, though present in the epidermic accumulations of cysts,1 are, I believe, never found in simple papillary growths, and are " well marked in nearly every epithelial cancer." Benign Epithelial Growths constitute a small proportion of laryngeal neoplasms. In these tumours, the epithelial scales do not clothe papillae, but form continuous layers of more or less undulating character. Nearly all laryngeal growths have an epithelial covering; but there are some neoplasms in which the whole growth is made up of epithelial cells (Plate I. fig. 2). These constitute, in fact, simple hypertrophy of the normal epithelium of the larynx : as already observed, many of the cases of (supposed) congenital growth are of this simple structure. In nearly all cases of laryngeal growth, the epithelium is of the tesselated variety; and Cornil - remarks that this holds good " even when the growth is developed in a part of the larynx, in which the mucous membrane possesses cylindrical epithelium." Ciliated epi- thelium has, however, been found on the surface of a laryn- geal neoplasm in three cases.3 In my 100 tabulated cases, benign growths were present in 5 instances ; of these two occurred in young children; and one other instance4 is related amongst my untreated cases. These growths, from the great diversity of the shape of the cells, are, when examined with the microscope, occasionally mistaken for cancer, but they never contain laminated capsules, and can therefore be easily distinguished from true epithelioma. Fibromata, though not nearly so common as papillomata, are next in order of frequency to those neoplasms. They 1 Mr. Paget, Op. cit., p. 720. See also Virchow, Archiv, vi. p. 200, quoted by Mr. Paget. 2 Quoted by Krishaber (Op. cit.) from Dr. ComiPs unpublished MSS. 3 Ehrmann (Op. cit., Observation xxii.); Follin (Appendix D, Case 56); Krishaber (Appendix D, Case 187). 4 Appendix B, Case 9. X. if - - \ Itt ?,Z/f? ■■; 7 >■*'#-.v^^V- ■"•.:'A^O&i---■ ■''-^v Plate 1. ( : ■>*:."$'■■ .:$■'■>'.£'r>~*r. *V '"4 r /-- -.-'..■.:■ J' ■>'■'xr ^ x 200 diarn. 4. k *&??*, 5 ^ ;; >\- \\y^^ i'/V>> 7 /^ 7 /. •;KJ'ilS< 'hmimm \i0 . The Bayonet Joint. A shorter or longer tube can be put on here, according to circumstances, and the blade can be taken out and cleaned. Sp. The Spring which forces out the lancet: when it is pressed down to the dotted line, the lancet, /, pro- trudes. h. The Handle—the same as that used for the forceps. Sc. The Screw, by turning which, the length of the point of the lancet can be regulated. 76 On Grozvths in tlte Larynx. when laryngoscopy was in its infancy, they have now almost fallen into disuse. Scissor-blades (fig. 4, 3) can be attached to my tube-forceps, but I have never been able to employ them with success ; for in order that scissors should act efficiently, it is necessary, first, that the substance to be cut, should have a certain degree of firmness, or tension, and secondly, that the blades should bite well in relation to each other. Neither of these conditions exists; for whilst the consistence and mobility of the growth render it difficult to be cut, the length, delicacy, and angular form of the instrument, as well as the mode by which the blades are, of necessity, made to approximate, are all adverse to its action. In addition, the blades of scissors cannot, of course, be made to open so widely as those of forceps, and it is necessarily much more difficult to seize a growth with a thin-edged instrument like scissors, than with the broad spoon-shaped extremities of forceps. Occasionally, where it has not been possible to entirely cut through a growth, incisions have been made into its structure : like crushing, this procedure has the effect of disturbing the nutrition of the neoplasm, and thus favours its degeneration by sloughing or atrophy. This treatment is only mentioned in conse- quence of its having been employed with success in Professor Bruns' first case: it is now entirely superseded by other and more certain methods. Ecraseurs.—It may, perhaps, be thought that the ecraseur does not act as a cutting instrument; but, in point of fact, the wire employed is so fine, that it actually does cut through the tissue. Growths have been removed with con- siderable success by means of the wire ecraseur or noose. It was first employed by Dr. Walker,1 of Peterborough, who was also the first practitioner, in this country, to extirpate a growth with the aid of the laryngoscope. His instrument was made on the principle of Gooch's canula, but bent at right angles, and much longer below the angle. Subsequently Sir Duncan Gibb invented a more convenient ecraseur, in whieh the wire is drawn through eyes at the 1 Lancet, November, 1861. Fig. 6.—Stoerk's Instruments. A. Ecraseur. B, C. Guillotines of various sizes. D, E, F. Forcep-blades of different kinds. In all cases, the instrument acts through an internal rod, a double wire being drawn through a tube-shank, which is attached to the handle at x. The movable part of the in- strument is attached by the screw, z ; and, in the case of the ecraseur, the ends of the wire are twisted round the peg, y. In using the instrument, the operator puts his thumb into the ring, o, and his index and second fingers through the rings,/ and q, and when traction is made on these rings, the ecraseur or forceps are drawn upwards. 78 On Growths in the Larynx. extremity of a curved metallic rod, instead of through the two canulae of Gooch's instrument. This ecraseur, at a later period, was still further improved by Dr. George Johnson. Treatment by ecraseur has also occasionally been carried out by Trelat, Moura-Borouillou, Bruns, Elsberg, and others. The various so-called ecraseurs were, up to a certain time, all open to the serious objection, that the wire was unpro- tected, and, being necessarily very flexible, it was very often pushed or bent on one side before the loop could be put round the growth. This difficulty was subsequently over- come by Dr. Stoerk, of Vienna, who first suggested that the wire should be concealed in a loop of rigid metal (fig. 6). It will be seen that Dr. Stoerk's instrument has almost the character of a guillotine, except that a wire is used instead of a cutting blade, and, as has already been shown, in all these instruments, division of the growth is accompanied by a quick cutting action, not by the slow squeezing movement of the true ecraseur. Though I have not used Stoerk's instrument exclusively in any one case, I have derived assistance from it in 4 per cent, of the cases here pub- lished.1 I have, however, had a true wheel ecraseur made for the larynx, and with it have succeeded in removing two large growths. In one case,2 the growth was the size of a cherry, and was attached to the under surface of the epiglottis; the other grew from the posterior surface of the cricoid carti- lage, and was as large as a bantam's egg. Both specimens were exhibited at the Pathological Society last year.3 One case is reported hereafter,4 but the other proving to be epithelioma, has been excluded. My "guarded wheel ecraseur" (fig. 7) is only adapted for large growths, and is especially indicated where haemorrhage may be anticipated. From the slowness with which the instrument acts, it can only be used when tracheotomy has been previously performed, or where the » Appendix A, Cases 57, 79, 84, and 86. 2 Appendix A, Case 88. 3 Pathological Transactions, vol. xxi. p. 51, et seq. * Appendix A, Case 88. Treatment— L aryngoscopic. 79 growth is external to the laryngeal canal {i.e. on the posterior wall of the cricoid cartilage or in the hyoid fossa, &c). In both my cases, the operation was done under chloroform. Fig. 7.—Guarded Wheel Ecraseur. Loops and Rings. — Loops or rings of rigid wire (fig. 8) can sometimes be employed with success. They should be curved at different angles, and be of different lengths. The opening of the loop should sometimes be in the antero-posterior, sometimes in the lateral direction, and sometimes inter- mediate between these two, so that different loops can be employed, according to the situation of the growth. It is convenient to let the inner edge of the wire be sharp, like a knife, and a kind of angular collar is not without its advantages. By means of these instruments a growth may occasionally be jerked, or scraped, off. No Danger in Ecraseurs or Wire Loops.—In the use of the small ordinary cutting ecraseurs I formerly feared that por- tions of the growth, separated in the operation, might fall down the windpipe, and give rise to serious irritation of the lungs; but experience has convinced me that this danger is chimerical, and that these instruments, if perhaps less useful than others, are nevertheless perfectly harmless. Guillotines.—Incision by guillotine was recommended at an early epoch of laryngology by Drs. Ozanam, Semeleder, Stoerk, and others ; but it is not at all a convenient mode of treatment. Not only is it difficult to press the instrument sufficiently against the parietes, but with a long slender curved Fig. 8.—Laryngeal Rigid Wire-Loops. a. Handle with screw for holding wire. 1 x. Outer smooth edge of a loop. b, c, d, e, f g. Different wires showing different z. Inner cutting edge of a loop. kinds of loops. I Treatment—Laryngoscopic. 81 instrument it is impossible to get the sudden forcible impulse which is required for a guillotine. The late Dr. Tiirck in- vented what he called a fenestrated knife (fenstermesser). This differed from Semeleder's guillotine, inasmuch as the protecting sheath of the blade was made square, instead of round, and the cutting blade, instead of being straight, was lancet-shaped, so that it presented two cutting edges. It does not appear to me to have been in any respect superior to the ordinary guillotine, and neither instrument is well adapted for the removal of laryngeal growths. Only very small guillotines can be used, and only a very small portion of a growth can, as a rule, be sliced off. I have never been able to employ these instruments with advantage. Chemical Treatment. Chemical treatment may be carried out either with caustics, escharotics, or galvanic cautery. Caustics.—Solutions of nitrate of silver are generally of but little use ; if employed, however, they should be exceed- ingly concentrated, and should be accurately applied, with a very fine camel's hair pencil, to the seat of disease. On reference to my own cases,1 but especially to those treated by other practitioners,2 it will be seen that when laryngoscopy was first introduced, growths were generally treated by the application of caustics. This was no doubt due to the circumstance, that at that period, practitioners were not aware, to how great an extent operations could be conducted within the larynx, and at that time, of course, no great manual dexterity in this department had been acquired. The small utility of this treatment is, however, demonstrated by the fact that since 1862 mechanical methods have almost entirely superseded the local applica- tion of caustics. In some of the earlier cases, the apparent success of caustic treatment was also probably due to defective 1 Appendices A and C. 2 Appendix D. II 82 On Growths m the Larynx. diagnosis, cases of condylomata and inflammatory thicken- ing having been mistaken for true growths. I, myself, have only seen caustic solutions of use in three cases.1 In one instance the growth was entirely destroyed, but in the others some diminution alone took place. On the other hand, I know of numerous cases, in which solutions of nitrate of silver have been applied persistently for several months, without producing any effect on the growth. The solid nitrate of silver is equally unavailing ; but it may sometimes be applied with advantage to the remains of a growth which has previ- ously been nearly removed by evulsion. In treating cystic growths, it is a good plan to apply caustic to the interior, after an incision has been made, and the contents of the cyst evacuated. The most convenient mode of applying it, is, to fuse a small quantity of the salt on to a piece of aluminium wire of suitable length and curve. Chromic Acid in my hands has proved as unsatisfactory for the destroyal of growths, as solutions of nitrate of silver. Escharotics.—On a few occasions I have employed escha- rotics with marked success, but only in a supplementary way. They may be used in cases, where numerous small growths cover a large surface of the mucous membrane of the larynx.2 I have occasionally employed nitric acid, but the escharotic which I have found most useful is " London paste." 3 To all caustics and escharotics, however, the objection remains, that if sufficiently powerful to be effective, they are very likely to cause spasm of the glottis, or to give rise to inflammation of the adjacent mucous membrane ; for this reason I now very seldom use them. Galvanic Cautery.—Galvanic cautery may be carried out 1 Appendices A and C, Cases I, 2, and 54. 2 Appendix A, Case 3. 3 This preparation consists of equal parts of caustic soda and unslaked lime. It should be kept as a powder, and only made into a paste with water when required for use. It differs from Vienna paste, in so far as soda is employed instead of potash, and water is used for mixing in place of alcohol: it is a far more manageable and less painful compound. It should be applied on the point of an aluminium rod, as I have recommended for nitrate of silver. Treatment—Laryngoscopic. 83 either with knife-like instruments, or with loops. This plan of treatment was first practised by Professor Middeldorpf, and has since been very successfully carried out by Dr. Voltolini, of Breslau, and other practitioners. Notwithstanding, however, that I have modified the latter physician's laryngeal electric- cautery instruments, and have had them made exactly on the principle of my laryngeal electrode, I cannot say that I have found the treatment well adapted for the destruction of growths. Professor Bruns strongly insists on the dis- advantages of galvanic-cautery treatment, and notices how " much more difficult it is to limit the caustic action of the glowing platinum loop to a small surface, than it is, when nitrate of silver is used." I have only employed galvanic cautery exclusively in three cases, and once in conjunction with other means.1 In one instance the patient complained very much of the painful character of the treatment, and in two cases it even gave rise to acute oedema, though fortunately of a very localized character. In addition to the inconvenience it causes to the patient, galvanic cautery gives a great deal of trouble to the practi- tioner. As the wires have to be very carefully isolated, the electrode is of course rather bulky, and the necessarily unwieldy covered wires, which are attached to the handle of the electrode, prevent the operator using the instrument with that delicate precision which is essential in all manipula- tions on the larynx. When to this is added the employ- ment of strong acids and a special electric apparatus, which requires some experience in its use, and the presence of an assistant at each operation, it will be seen that the employment of electric cautery introduces a number of complications and difficulties in the way of the operator. Further, as an instantaneous white heat ought to be pro- duced, the wire at the extremity of the instrument must be exceedingly fine, and is therefore constantly destroyed by combustion. Hence it happens that the instrument is con- tinually in the hands of the instrument-maker. There are, Appendix A, Cast> jS, 41. 42, and 49. 84 On Growths in the Larynx. indeed, no special advantages to be derived from this method : the other modes of treatment are amply sufficient, and there is no particular kind of growth for the destruction of which electric cautery is indicated. It will be seen, there- fore, that, as far as my experience goes, this treatment is not to be recommended. Extra-Laryngeal Methods of Removing Growths. In certain cases, it unfortunately happens that growths in the larynx cannot be removed through the mouth. The introduction of the laryngoscope, by rendering the diagnosis of laryngeal growths for the first time possible, and even easy, has not only led to the valuable laryngoscopic treat- ment already described, but it has given an increased prospect of success to the various surgical operations by which the cavity of the larynx is laid bare. Not only does the laryngoscope reveal the situation of the growth, but its extent and nature can generally be ascertained. These circumstances enable the surgeon to adapt the operation to the special circumstances of the case, and teach him to avoid operating in those of an unsuitable character. The difficulty of laryngoscopic treatment may be due to the large size or extreme density of a growth, to its inacces- sible situation, or extensive origin; to the occurrence of inflammatory tumefaction, or spasm of the glottis, on at- tempted evulsion through the mouth ; to great irritability of the fauces, or to an unusually nervous and excitable state of the patient. In the case of very young children also, an extra-laryngeal method may be necessary. The large size of a growth does not, in itself, call for external treatment, some of the largest growths having been removed per vias naturales.1 The extreme density of a 1 Appendices A and C, Cases 3, 52, 92, 95, &c. Treatment—Extra-Laryngcal Methods. 85 growth sometimes presents a great difficulty to laryngoscopic treatment, but with strong cutting forceps, this difficulty is only insuperable in the case of ecchondroses, and it is very questionable whether radical treatment should be attempted for their removal. The growth may be so situated that it cannot be completely eradicated from above. This occasion- ally happens in the case of growths springing from the anterior wall of the larynx below the vocal cords. In one of my cases of this sort, the evulsion was incomplete,1 but in two others the growth was entirely eradicated. When a growth, however, is situated in the ventricle, and only slightly projects from the ventricular orifice, it is sometimes impossible to remove it entirely from above. The projecting portion may be cut off, but the base remains. The question arises in these cases, whether the growth should be removed from time to time, as it sprouts out of the ventricle, or whether an external operation should be performed. Should a large tumour gradually extend the ventricle and push the ventricular band before it, direct incision into the larynx, and subsequent incision into the ventricle, might possibly be called for ; but as a matter of fact, as soon as the ventricle becomes at all tense, the growth emerges from the ventri- cular orifice. Indeed, even before the ventricle becomes at all full, the disposition to growth naturally takes place at that point where the resistance is least, and neoplasms, originating in the ventricle, emerge at an early period from its cavity. The extensive origin of growths greatly increases the difficulty of their removal, especially when there is an independent multiple development. Though this occurred in 3 of my cases, I was able to remove the growths through the mouth in 2 of them.2 Difficult as it is, in such cases, to effect evulsion per vias naturales, it would probably be not less difficult to accomplish complete eradication by an external operation. ' Appendices A and C, Case 24. 2 Appendices A and C, Cases 3, 46, and 98. 86 On Growths in the Larynx. The occurrence of inflammation or spasm of the glottis, on attempted laryngoscopic treatment, may render the com- bined method necessary (tracheotomy having first been per- formed, and evulsion being subsequently effected through the fauces), but it does not in itself justify an extra- laryngeal operation for evulsion. An insuperable irritability of the fauces, or an extremely nervous condition of the patient, may, however, render laryngoscopic treatment impossible; and in these cases an extra-laryngeal treatment may be necessary. In the case of young children who cannot be taught to submit to laryn- goscopic treatment, extra-laryngeal treatment may be re- quired ; but it must not be forgotten that very young children have been successfully treated with the aid of the laryngeal mirror. In one of my cases,1 the patient was only four years old, and in another 2 only six. In a case 3 treated by Professor Bruns, the child was only five years old, and though the neoplasms showed an extreme disposition to exuberant growth and multiplication, portions of the neo- plasms were removed through the mouth and others destroyed with caustics. Contra-Indications for extra-Laryngeal Methods.—It may be stated as a cardinal law, that an extra-laryngeal method ought never to be adopted (even where laryngoscopic treatment cannot be pursued) unless there be danger to life from suffocation or dysphagia. Direct incision into any part of the air-passages is always attended with both immediate and remote danger to life, the amount of risk being dependent on the situation of the opening, and on the mode in which the treatment is carried out. The various degrees of danger will be considered when discussing the merits of the different extra-laryngeal methods, and it is sufficient here to remark, that the existence of dysphonia does not justify operations, 1 Appendix A, Case n. 2 Appendix A, Case 12. 3 Appendix D, Case 89. In this case, tracheotomy had been performed some years before the little patient was placed under Dr. Bruns' care but his treatment was mainly carried out through the mouth, with the aid of the laryngeal mirror. Treatment—Extra-Laryngeal Methods. 87 which, though easy to perform, may be regarded as " capital." Hence an extra-laryngeal operation is not justifiable for the removal of a small growth in the larynx, unless that growth give rise to dangerous dyspnoea, and cannot be removed by a less serious method. No doubt a direct incision into the larynx offers a readier and more brilliant method of extirpa- tion than the more tedious process of laryngoscopy, but to do an external operation where laryngoscopic treatment could be ultimately successful is not less reprehensible than to per- form lithotomy in a case of calculus, in which lithotrity could be effected, or to amputate a limb where resection could be accomplished. A dangerous operation, even though suc- cessful, is not justifiable, when a perfectly safe method might have been adopted. At least one case, if not more, has been reported in which the growths might easily have been removed through the fauces, and in which neither the size of the growth nor its situation justified the external operation.1 If these improper cases were withdrawn from the various statistics in which they appear, the results of external incision would appear much more unfavourable. Contra-indications based on danger to life, having been thus briefly pointed out, it only remains for me to remark that destruction of the vocal function is often the result of the most available extra- laryngeal method. Extra-laryngeal methods of extirpation may be carried out in one of three ways :—1st, By division of the thyroid cartilage, or thyrotomy; 2ndly, by supra-thyroid laryn- gotomy, or division of the thyro-hyoid membrane; and 3rdly, by infra-thyroid laryngotomy (through the crico- thyroid membrane), or tracheotomy. 1 It is certainly remarkable that there should have been seven cases published from the small town of Buda-Pesth with its 200,000 inhabitants ; whilst from London and Paris, with their 5,000,000 inhabitants, only six cases have been as. yet recorded. 88 On Grozvths in the Larynx. Division of the Thyroid Cartilage, or Thyrotomy. Indications for Operation.—This operation maybe required for the removal of large growths in the cavity of the larynx, causing great dyspnoea or dysphagia, which cannot be removed with the aid of the laryngoscope, or for the evulsion of growths in the sub-glottic region, which cannot be extirpated by in- direct laryngotomy (through the crico-thyroid membrane). It might be thought that this operation would be called for in the case of children ; but the facility with which they can be treated laryngoscopically has already been pointed out ; and it must not be forgotten that when the larynx is small, thyrotomy is much more likely to lead to injury of the vocal cords. It may be remarked that in several of the cases, hereafter reported, the disease having been cancer, the operation was of very doubtful utility; whilst in others, the growths were small, and with patience and perseverance could probably have been removed through the mouth. Ossification of the cartilage is in no sense a contra-indjca- tion for the operation. It adds little to its difficulty, though union afterwards takes place rather more slowly. History.—This important operation was first proposed for the removal of laryngeal growths by Desault, at the end of the eighteenth century. His remarks, which were per- fectly true before the invention of the laryngoscope, are as follows:— " In cases of polypi of the larynx, the indications are twofold; viz. the extirpation, or ligature of the growth, and the re-establishment of a passage for air; and they both necessitate laryngotomy. It rarely happens, indeed, that laryngeal excrescences project so far into the mouth, that they can be seized and extirpated or ligatured per vias naturales."1 1 This quotation is taken from a later edition of Desault's CEuvres chirurgi- cales, by Bichat. Paris, 1812, vol. ii. p. 255. Treatment—Thyrotomy. 89 The operation was not, however, carried out till the year 1833, when it was performed for the first time by Brauers of Louvain. Ten years later it was repeated by Ehrmann of Strasbourg. In 1851 it was practised by Gurdon Buck, and again by him in the year 1861. The invention of the laryngoscope naturally gave an impetus to this opera- tion, and its progress will be at once evident on reference to the Thyrotomy Table on pages 92 and 93. Method of Procedure.—The first question which arises is whether tracheotomy should or should not be performed as a preliminary measure of safety. In some cases, this precau- tion has been taken, whilst in others it has not been adopted. Tracheotomy should, in my opinion, always be performed, in the first instance. Three advantages are thereby gained, and no additional danger is incurred :—1st, the danger of suffocation, from blood passing into the trachea, is avoided ; 2ndly, the operation can be performed with greater delibera- tion, and the growth can be removed with more certainty ; 3rdly, if laryngitis should subsequently supervene, the patient is in a condition of safety. The danger of suffocation during the operation is by no means chimerical; for although, in some cases, no evil has resulted from the neglect of this precaution, in two instances l in which the operation was attempted without tracheotomy, the patients almost died from blood passing down the wind- pipe, and in both cases, an incision had to be quickly made from the second ring of the trachea to the thyro-hyoid membrane. If a small growth the size of a pea or tare be removed by thyrotomy, it may not be so necessary to per- form tracheotomy in the first instance; but as I do not consider that an extra-laryngeal method is justifiable for the extirpation of small growths, such cases are excluded from consideration. When the patient has recovered from tra- cheotomy, that is to say when all bleeding, coughing, and spasmodic movement of the larynx have ceased, the incision should be made exactly in the median line, through the 1 Thyrotomy Table, \os. 19 and 23. 12 90 On Growths in the Larynx. textures over the thyroid cartilage, from the thyroid notch to the upper border of the cricoid cartilage. The thyroid cartilage should then be most carefully divided by a succes- sion of small nicks, with a short, strong, sharp-pointed knife; but if ossification have taken place, the opening must be effected with a small rircular or convex saw. The instru- ment should not be allowed to penetrate the larynx until the whole of the cartilage is divided.1 By this method the paroxysms of coughing, which otherwise interfere with the operation, are often avoided. When divided, the alae of the cartilage should be kept widely apart by means of strong retractors held by two assistants, one on each side of the patient. The retractors2 should be like miniature pitchforks, with the points blunted and bent round, so that they can hold back the alas. If the alae cannot be thrown back, the crico-thyroid mem- brane should be divided along the lower edge of the thyroid cartilage, on one side, or, if necessary, on both sides. If there be still insufficent room, the thyro-hyoid membrane should be divided, by a horizontal section along the upper edge of the thyroid cartilage. Horizontal division of the membranes, however, is not generally necessary, and the thyro-hyoid should if possible be left intact. The operator should now throw a strong reflected light into the opening, and, guided by it, and his previous laryngoscopic knowledge of the case, he will be able to seize the growth with a hook or forceps, and divide it with a pair of short curved scissors. On account of the small space at the com- mand of the operator, the growth may sometimes be divided, without being previously seized, or it may be torn away with forceps. The base of the growth should then be firmly touched with solid nitrate of silvef. Actual cautery, acid nitrate of mercury, and galvanic cautery, have all been used, but I prefer the nitrate of silver, as less likely to give rise 1 This precaution is justly insisted on by Krishaher and Planchon (Fails cliniques de Laryngotomie. Paris, 1869, p. 93). 2 This form of retractor is better than a solid plate of metal, as, when in use, it does not hide the laryngeal surface. Treatment— Thyrotomy. 91 to laryngitis, and quite as effectual when applied to a raw surface. The two alae of the thyroid cartilage should then be carefully brought together, in their exact normal situation, with two silver sutures, and-the edges of the wound united with plaster. The canula should be allowed to remain in the trachea, for, at least, a few days, until all danger has passed off; or if there be any likelihood of recurrence, till further steps have been taken to effect complete eradication. In some of the cases contained in the annexed Table, the cricoid cartilage was divided, and though no harm appears to have resulted from its section, it is better, if possible, to leave it intact. This precaution is, I believe, one of considerable importance in relation to the subsequent result of the opera- tion ; for as it is often necessary that the patient should wear the tracheal canula at least for a few days after the operation, and sometimes for weeks or months, if the cricoid cartilage has been divided, the tube is likely to be constantly pushed up against the thyroid cartilage in coughing, and this pressure is almost certain to interfere with the proper union of the two parts of the thyroid cartilage. Krishaber1 justly remarks that division of the cricoid cartilage is altogether unnecessary; for whilst, on the one hand, it does not facilitate the removal of growths above the vocal cords, those below the glottis can easily be removed either through an opening in the crico-thyroid membrane or the trachea. Comparative Merits of Thyrotomy.—Unlike the operation conducted per vias naturales, in being unattended with danger to life, or risk of destruction of function, the pro- cedure now under consideration is a very serious one. Its results will be best appreciated by an investigation of the annexed Table. 1 Op. cit. 92 On Growths in the Larynx. THYROTOMY TABLE, showing results, as regards life and voice, in all cases of laryngeal growth, whether malignant or benign, in which thyrotomy was performed.1 No Date. I 1833 2 1844 3* I85I 4 1861 5 1861 6* 1862 7 1863 8 1863 9 1863 IO* 1864 ii 1864 12 1864 13 1864 14 1865 15 1865 16 17 1866 1866 Operator. Brauers, Louvain ... (Ehrmann, Op. cit., p. 12.) Ehrmann, Strasbourg (Op. cit., p. 18.) Gurdon Buck,a Ame- rica............ (New York Medical Journal, May, 1865) Rauchfuss, St. Peters- burg. Gurdon Buck, Ame- rica ............ Sands, America (New York Medical Journal, May, 1865.) Boeckel, Strasbourg... Busch, Bonn ...... Debrou, Paris...... Gibb and Holthouse, London. (Brit. Med. Journal, Sept. 30, 1865.) Lewin & Ulrich, Ber- lin. Gilewsky, Cracow ... Gouley, America ... Balassa, Pesth Koerberle, Strasbourg Balassa, Pesth...... Ditto ...... Operation. Thyrotomy without Tracheotomy. Thyrotomy with Tra- cheotomy (Cricoid di- vided). Thyrotomy with Tra- cheotomy and partial removal of growth (Cricoid divided). Thyrotomy with Tra- cheotomy (Cricoid divided). Thyrotomy, preceded by Tracheotomy 5 months previously (Cricoid divided). Thyrotomy with Tra- cheotomy (Cricoid divided). Thyrotomy with Tra- cheotomy (Cricoid divided). Thyrotomy with Tra- cheotomy (Cricoid divided). Thyrotomy with Tra- cheotomy (Cricoid left intact). Thyrotomy, preceded by Tracheotomy 8 days previously (Cri- coid divided). Thyrotomy with Laryn- gotomy. Thyrotomy only (Cri- coid left intact). Thyrotomy, preceded by Tracheotomy 10 weeks previously (Cri- coid divided). Thyrotomy with Tra- cheotomy (Cricoid divided). Thyrotomy only...... Thyrotomy only...... Thyrotomy with Tra- cheotomy (Cricoid divided). Result. Death. Persistent Aphonia. (Death from typhus 7 months later.) Death 18 months later. Persistent Aphonia. Canula always worn. Death in 2 years. Persistent Aphonia. Persistent Aphonia. Recurrence of growth. Canula always worn. Death 22 months later, from malignant disease of supra-renal capsules. Voice never normal. Death in 2 months, from Pneumonia. Persistent Aphonia. Persistent Dysphonia. Recurrence of growth. Canula still worn. Death in 7 days, with metastatic abscesses in both lungs. Death in 1 year. Persistent Dysphonia. Recurrence of growth. Cure. " Voice much deeper after operation." Persistent Dysphonia. Persistent Aphonia. Normal respiration. Cure. Persistent Aphonia. Still wears canula. Cure. Cure, though growth was incompletely removed. Treatment—Thyrotomy Table. 93 No. Dale. Operator. Operation. Result. 18 1867 Balassa, Pesth...... Thyrotomy with Tra-cheotomy (Cricoid divided). Great benefit, but re-moval of growth incom-plete. Thyrotomy performed a second time without Tracheotomy. Ultimate Cure. 19 1867 Cutter,b America ... Ditto ditto...... Persistent Dysphonia. Recurrence of growth in less than a month after operation. 20 1868 Mackenzie and Cou- Ditto (Cricoid left Cure. Recurrence 2 per, London. intact). years later. 21 1868 Mackenzie and Evans, London. Ditto ditto...... Persistent Aphonia, but respiration normal. 22 1868 Xavratil,c Berlin Thyrotomy only (Cri-coid left intact). Persistent Dysphonia. 23 1868 Dittod ......... Thyrotomy with Tra-cheotomy (Cricoid divided)! Growth not removed. 24 1868 Dittoe ......... Thyrotomy only (Cri-coid divided). Cure. 25* 1869 Schroetter, Vienna ... Thyrotomy with Tra- Death from haemorrhage (Medicin Jahrbiicher, cheotomy (Cricoid in 7 hours. Wien, 1869, vol. xvii. divided). 2nd Heft, p. 81.) 26* 1869 Mackenzie and Words- Thyrotomy, preceded Death in 6 months. worth, London by Tracheotomy 14 days previously (Cri-coid left intact). Persistent Dysphonia. 27* 1869 Cohen,f America Thyrotomy with Tra- Condition of voice not (New York Medical cheotomy. stated. Record, Aug. 16, Recurrence began to 1869.) manifest itself a fort-night after operation. 28 1862 Krishaber, Paris Thyrotomy with Tra-cheotomy (Cricoid Cure. left intact). 1 The reference applicable to each case, where it is not inserted in the text, will be found in Appendices A or D. * These six cases were malignant or semi-malignant. a In May, 1851, section of thyroid and cricoid cartilages and trachea, removal of growth and insertion of canula. In the following September, section up to the hyoid bone and an inch below permanent orifice in trachea. Second removal of growths, re-insertion of canula. In January, 1852, tracheotomy performed lower down. In August patient was accidentally suffocated in changing canula. b Thyrotomy was performed in the first instance; but as the patient almost died under the operation, from blood passing into the trachea, an extensive incision had to be made from the upper rings of the trachea to the thyro-hyoid membrane. Improvement in voice is reported ; but as the growth recurred in less than a month, persistent aphonia would probably more correctly describe the condition. c The right vocal cord was wounded in the operation, and a portion of it afterwards sloughed away. The growth was only the size of a pea. d An extensive incision was made, but the patient nearly died from haemorrhage. Owing to the intimate connection of the growth with the subjacent parts, it could not be removed. e In this case the growth was not larger than a split tare. After the operation, great oedema took place around the wound. The patient also expectorated a quantity of blood and pus, and suffered from high fever. The voice remained hoarse for some time, but was ultimately restored by inhalations. 1 I have not been able to obtain the JViiu York Medical Records, and my information respecting this case has been obtained from Yirchow's Jakrcsbcrichte ueeer die Fortschritte, 1870, vol. ii. p. 117. 94 On Grozvths in the Larynx. In order to thoroughly weigh the merits of thyrotomy, it is necessary to consider the prospects of the operation : (ist), in relation to the preservation of life ; (2ndly), in relation to the recovery of voice ; and (3rdly), in relation to the immunity from recurrence. Each of these points will now be con- sidered in detail. (ist.) In Relation to Life.—In division of the laryngeal cartilages, there is always some immediate danger, and 9 out of the 28 cases on record, terminated fatally. In one case the patient died from haemorrhage seven hours after the operation. In another, the patient lived only seven days, death taking place from pleurisy, and metastatic abscesses in the lungs. In a third, fatal pneumonia supervened at the end of two months. In Dr. Cutter's case (No. 19), the patient was almost suffocated during the operation; and in one of Navratil's cases (No. 23), the haemorrhage was alarming, and the patient nearly died under the operation, from the quantity of blood which passed down the trachea. In another of Navratil's cases (No. 24) the patient suffered from high fever after the operation, and expectorated a quantity of blood and pus: oedema took place round the wound, and the patient was in a very critical state. The usual risks attending the ordinary operations for opening the air-passages, are also, of course, present, and tracheitis or bronchitis may supervene. In addition to the immediate danger, there is also the contingent risk of chronic perichondritis at a later period, and, as is well known, disease of the cartilages of the larynx, under these circumstances, is synonymous with laryngeal phthisis. This result has, however, only occurred once in the twenty-eight cases in which thyrotomy has been performed.1 In six of the nine fatal cases in the Thyrotomy Table, the disease was cancerous (or semi-malignant), but in at 1 In Brauers' case, the repeated destruction with the actual cautery produced great constitutional disturbance. " Le larynx passa a l'etat d'induration squir- reuse, une fievre hectique s'alluma," and the patient slowly sank. In this case the induration was probably due to inflammatory thickening and disease of the cartilages. Treatment— Thyrotomy. 9 5 least one of these, the patient, who might have lived for months, or even a year or two, died from the immediate effect of the operation, and in the others, with one exception, there is no reason to think that the operation was more beneficial than simple tracheotomy would have been. Comparing this table with the result of my 93 cases treated through the natural upper orifice of the larynx, it will be seen that the prognosis in thyrotomy is much more unfavourable ; for whilst in 28 cases of thyrotomy 9 patients died, not one of my cases terminated fatally. Mr. Durham1 gives a table, which, although it makes the operation of thyrotomy appear to be rather less dangerous (probably by massing together cases of indirect laryngotomy with thyrotomy), nevertheless shows how much more success- ful are operations conducted per vias naturalcs. His table gives 24 cases of external incision into the larynx, with 4 deaths, and 114 cases of operations through the mouth, with only 3 deaths. The operation as regards life, is, indeed, probably much more unfavourable than the Thyrotomy Table would indicate, for many cases, in which the operation was performed, were not at all urgent, and had the operation been practised in necessary cases only, the results would have appeared still less satisfactory. Again, it is highly probable that the operation has been ////successfully performed in some unpublished cases, and the well-known preference which practitioners have for recording their favourable cases must not be forgotten. (2ndly.) /// Relation to Voice.—However carefully thyrotomy is performed, there is always a danger of wounding the vocal cords. In some cases this injury may be avoided, but in others, owing to the rapid ascent and fall of the larynx, which takes place when a foreign body is first in- troduced into the air-passages, it is impossible to prevent wounding the vocal cords. This contretemps is stated to have occurred once—viz., in Dr. Cutter's operation; but though unnoticed, it probably happened more frequently. In the case in which the accident is recorded, the injury 1 Op. cit., p. 5S4. 96 On Growths in the Larynx. was followed by loss of substance. In another case, that of Dr. Rauchfuss, it was necessary, in order to extirpate the growth, to cut away one of the vocal cords. I do not think, however, that slight injury of the vocal cords is necessarily attended with subsequent loss of function. The aphonia which so often results from thyrotomy, is pro- bably due either to inflammatory changes in the hard or soft tissues, near the commissure of the vocal cords, or to a slight dislocation of one, or both of the cords, at their anterior extremity. If, in the union of the thyroid carti- lages, the two halves are brought together, so that one cord is, in the very least degree, above the level of the other, the correlation between the two cords must necessarily be de- stroyed, and aphonia result. Or again, in bringing the two alae of the thyroid cartilage together, especially when the connect- ing crico-thyroid and thyro-hyoid membranes have been divided, the level of the pomum Adami may be altered. Any modification of position at the anterior part of the larynx, of course alters the plane of the vocal cords, and thus affects vocalization. In some cases, the aphonia is probably due to the extensive origin of the growths, and to their intimate incorporation with the subjacent tissues; but that it is due in most cases to the operation itself, is shown by the fact that when thyrotomy is practised for the removal of foreign bodies, the voice is often lost. Out of six cases of this kind collected by Planchon,1 the voice is only stated to have been retained twice ; in one instance there was persistent aphonia, in another slight hoarseness, and in two cases the condition of the voice after the operation is not stated. Whatever may be the rationale of the phenomena, the very frequent persistence of aphonia or dysphonia after thyrotomy is indisputable. Out of the 28 cases contained in the Thyrotomy Table, the voice was only restored 8 times. Three of the cases, however, proved rapidly fatal, and in 1 the operation had to be abandoned. There remain, there- fore, only 24 cases. In 6 of these the patients died in a 1 Op. cit. Treatment— Thyrotomy. 97 few months (or in less than 2 years), 4 having remained aphonic, and two having been dysphonia Of the remaining 18 patients who survived, 5 suffered from permanent aphonia, 4 from persistent hoarseness, and 8 completely recovered the voice. In I case the result is not stated, but as recurrence took place within a fortnight, the voice could not have been improved. In my 93 cases, in which internal treatment was adopted, the voice was entirely restored in 75 instances, and in 15 there was improvement of the voice. The advantage of laryngoscopic treatment in respect to restoration of function, is so obvious, that it requires no comment. (3rdly.) /// Relation to Recurrence of Growth.—It might be expected that extirpation could be more completely effected when the thyroid cartilage is divided, and the larynx thoroughly exposed to view, and that thus recurrence would be less frequent; but hitherto this does not appear to have been the case. On analyzing the Thyrotomy Table, it appears that 4 cases rapidly terminated fatally, and therefore gave no time for recurrence.1 In 6 other cases, the patient died at the end of a few months, and in nearly all of these, recurrence had taken place. They were all, however, of malignant or semi- malignant character, and therefore the tendency to repro- duction was no doubt very great. Of the remaining 18 cases, in one (No. 23) the growth could not be extirpated at all, owing to its close incorporation with the subjacent tissues; and in two others (Nos. 17 and 18) the neoplasm was incompletely removed. In addition to these cases of incom- plete extirpation, which would be much more numerous if the fatal cases were not eliminated, recurrence took place in two cases (Nos. 19 and 27) in less than a month, and in one case (No. 20) at the end of two years. In my 93 cases, treated through the fauces, recurrence took place in 6 cases, in which the growth had been previously 1 This includes Ehrmann's case, which is justly considered as a case of recovery with aphonia, the patient having died from typhus ; as, however, she only lived >even months, there was not time to form an opinion as to recurrence. 13 9« On Growths in the Larynx. completely extirpated. In several of these cases the recur- rence did not take place till a year or two after evulsion had been effected ; and in most cases the neoplasm occurred in different situations to that which it had previously occupied. In three cases in which incomplete evulsion l was effected, but the symptoms were relieved, the growth after a time underwent further development, and again necessitated treat- ment. In one case 2 continuous growth has taken place. It will be seen, therefore, that thyrotomy does not even effect such complete evulsion as laryngoscopic treatment. Removal of Growths by Division of the Thyro- hyoid Membrane, or Supra-Thyroid Laryn- gotomy. Indications for Operation.—This method of treatment is indicated for the removal of large growths situated at the upper orifice of the larynx, which cannot be taken away per vias naturalcs. History.—This operation, originally proposed at about the same time by Malgaigne3 and by Vidal4de Cassis, was first carried out in the year 1859. The operator was Dr. Prat, a surgeon in the French navy, stationed at that time at Papiete, the capital of Otaheite. The patient, who was the subject of advanced pulmonary phthisis, suffered also from such extreme difficulty of swallowing, that he could scarcely take any food. The dysphagia was due to a growth, which appears to have been situated on the under-surface of the epiglottis; it could be felt with the finger, but all attempts to seize and remove it through the mouth entirely failed. By operating after the manner recommended by Malgaigne, Dr. Prat easily removed the growth, which was of a com- pact fibrous tissue and greyish-white colour. No vessels 1 Appendices A and C, Cases 37, 61, 74. 2 Appendices A and C, Case 59. The claim to originality is made by Malgaigne in his Manuel de Me'decine operatoire. Paris, 1871, 7me edition, p. 525. 4 Velpeau, Me'decine operat. Treatment—Supra-Thyroid Laryngotomy. 99 were tied. The wound healed quickly, and the symptoms from which the patient had suffered, disappeared. He died shortly afterwards from phthisis, and at the autopsy no trace of the growth was to be found.1 Had this difficult, and at that time unique operation, been performed, with the aid of able colleagues, in a first-class European capital, it would have reflected great credit on the practitioner; but when it is recollected that it was done by a naval surgeon in one of the small Polynesian Islands, it is impossible to speak too highly in praise of the boldness and skill of the operator. In the year 1863 Follin* performed a similar operation with complete success. The patient was a young man, aged 21, whose respiration was normal when in the horizontal position, but who could not breathe when standing upright. His symptoms were due to the presence of several fibro-cellular or myxomatous growths, which had rapidly formed, and were thought to be situated on the posterior wall of the larynx. The neoplasms were extirpated, and the patient was entirely cured. Dr. Follin thus describes his case :—" The operation was performed on the 24th of February, 1863. In order to avoid section of the base of the epiglottis, the incision was made at about 1-8th of an inch above the upper border of the thyroid cartilage. The skin, areolar tissue, internal fibres of the platysma myoides, and the sterno-thyroid and thyro-hyoid muscles, were divided. The superficial incision was about 2J inches in length, but in the deeper parts it was much less extensive. No arterial ligature was required, and the venous haemorrhage was exceedingly slight. The fatty mass in front of the epiglottis was divided, and the laryngeal mucous membrane being divided with scissors, the cavity of the larynx was laid open. This incision, which passed below the base of the epiglottis, led at once to the polypi; and the superficial parts being retracted, about ten excrescences of various size, some as large as Barcelona nuts, were successively removed with great ease by torsion 1 Gazette des Hopi/aux, 1859, \o. 103, p. S09. 1 Appendix D, Case 56, and Archives Generates de Mcdccine, Fevrier, 1867. 100 On Grozoths in the Larynx. or slight incisions with scissors." The wound healed rapidly, and the patient left the hospital on the 16th of March, perfectly cured. It should be mentioned in this case, that numerous unsuccessful attempts were made in the first instance to remove the growth through the mouth, but the extreme irritability of the pharynx rendered laryngoscopic treatment impossible. Method of Procedure.—Transverse incision through the thyro-hyoid membrane should, according to Malgaigne, be made along the lower border of, and parallel with, the hyoid bone, through the skin, superficial fascia, the inner half of the sterno-hyoid muscles, the thyro-hyoid mem- brane, and the mucous membrane which extends between the base of the tongue and the epiglottis, and forms the glosso- epiglottic ligament. The side of the epiglottis should then be seized and drawn through the wound. The growth can then be removed, according to the circumstances of the case, by bistoury, scissors, or forceps. It will be recol- lected that Follin divided the thyro-hyoid membrane along the upper border of the thyroid cartilage, that is, rather lower down than advised by Malgaigne, with a view of avoiding the epiglottis ; and as far as I can gather from the report of his case, the incision was carried further outwards than in Prat's case. The latter procedure certainly renders the epiglottis less likely to be wounded, but little immunity is afforded to the valve by making the incision a few centi- metres lower down than recommended by Malgaigne. It must also be remembered that the more external the incision is carried, the greater is the danger of wounding important vessels. In any case, the hyoid branch of the thyroid is not unlikely to be wounded, but this is not a matter of any importance. Comparative Merits of Operation.—Although sub-hyoid laryngotomy is unattended with any considerable danger, either immediate or remote, I do not think that it will find much favour with those skilled in operating with the aid of the laryngeal mirror; for it happens, that those cases which are favourable to the performance of this operation, Treatment— Supra-Thyroid Laryngotomy^ IoI are just those which, as a rule, can be most easily treated through the mouth. The two cases in which it has been carried out, are not sufficient for the deduction of any conclusions as to the value of this mode of treatment ; but it appears to me almost certain that in Prat's case the growth might have been removed through the fauces, had the laryngoscope1 been in use at that time. From the ease with which the growth was removed, it is highly probable that it was situated on the upper or lingual surface of the epiglottis, or, at any rate, on the edge of the valve. In Follin's case, the polypi were thought to be " attached to the mucous membrane covering the anterior surface and bases of the arytenoid cartilages," but it is much more pro- bable that they grew from the posterior wall of the pharynx. In the report they are stated to have " only covered the posterior half of the glottis;" and taking their number and size into consideration, it is quite impossible that they could have been situated as described. Had there been room for them in the larynx, they must have given rise to permanent dyspnoea, and must have covered more than the posterior half of the glottis ; on the other hand, if the growths had been attached to the posterior wall of the pharynx, the occur- rence of dyspnoea, when the patient stood up, would be explained. In the case of. large growths, as already pointed out, the origin is so often concealed, that it is not improbable that a slight error as to the origin of the growth may have been made. The operation is much less serious than thyrotomy, in relation to life, and is not attended with any risk to the vocal function. In injury of the cartilages which form the framework of the larynx, there is, as has been already pointed out, always the danger of subsequent caries; but it is well known that injury of the elastic cartilages, though it may cause temporary inconvenience, is unattended with 1 Although the laryngoscope was brought into use in 1859, the year of Prat's operation, it is highly improbable that it had reached the Polynesian Islands at that time. 102 On Growths in the Larynx. permanent risk. Not only do we frequently find that patients, recovered from tertiary syphilis, with the mere stump of an epiglottis, can swallow perfectly well ; but it has already been proved, in the celebrated case of Prince Murat,1 that the epiglottis may be suddenly cut away with only temporary inconvenience. Again, most hospital surgeons must have frequently met with extensive suicidal wounds of the thyro- hyoid membrane involving the epiglottis, which have healed rapidly without any bad results. This last fact has been illustrated by some remarkable cases by Kiinst.2 Removal of Growths by Infra-Thyroid Laryn- gotomy (through the Crico-Thyroid Membrane), or by Tracheotomy. Indications for Operation.—This operation is recommended for the removal of laryngeal growths situated in the sub- glottic region, as well as for tumours in the upper part of the trachea, when, in such cases, laryngoscopic treatment can- not be carried out. History.—This mode of eradicating growths was recom- mended by Professor Czermak in the year 1863 ; but it was first successfully employed two years later by Dr. Burow, senior,3 of Koenigsberg. In the year 1869, it was carried out, for the second time, by myself.4 In Dr. Burow's case the patient was a man, aged 48, who had a growth at the anterior part of the right vocal cord, which blocked up rather less than one-third of the laryngeal cavity, and produced dysphonia and dyspnoea. After re- peated unsuccessful attempts to remove the growths through the fauces, Dr. Burow made an opening in the crico-thyroid 1 In this historical case, which occurred at the battle of Aboukir, half of the epiglottis was carried away by a musket-ball. Under Baron Larrey's treatment the patient recovered. Another similar case occurred in the same campaign, with an equally fortunate result.—(Larrey, Clinique chirurg., torn. ii. p. 142 ; Relation chirurg. deI'Arme'e d'Orient, p. 286, quoted by Ryland.) * Eroff. der oberst. Luftxvcge. Leipzig, 1864, p. 45. 3 Deutsche Klinik, vol. xvii. p. 165 ; and Appendix D, Case no. * Appendices A and C, Case 81. Treatment—Infra-Thyroid Laryngotomy. 103 membrane, and succeeded with a hook in removing almost the entire growth. No canula was inserted. The patient's breathing, became immediately easy, and the voice clearer. When the patient was discharged, his voice, though much improved, was not quite resonant. As a proof of the very slight constitutional disturbance produced by the operation, Dr. Burow states that his patient left the hospital an hour after the operation, and that he was never confined to his bed, nor even to the house. In my own case, which is hereafter related in detail, the patient, a woman, aged 51, was admitted into the Hospital for Diseases of the Throat, on May 27th, 1869, on account of extreme dyspnoea. On laryngoscopic examination, it was seen that there was paralysis of the abductors of both vocal cords ; so that the glottis was reduced to the narrowest chink, and no view could be obtained of the parts below. Laryn- gotomy was at once performed, on account of the dyspnoea ; and it was not till a week later, that, on the first laryngoscopic examination after the operation, a growth was discovered to be the mechanical cause of the paralysis. The neoplasm was easily removed with curved forceps, introduced through the wound. The tube was removed six months later. The respiration remained normal and perfectly natural eighteen months after treatment. At the time, when this patient was under my care, I was not acquainted with Dr. Burow's interesting case. MetJwd of Procedure.—An incision should be made as in ordinary (crico-thyroid) laryngotomy, but the crico-thyroid opening should be carefully dissected out, and all the mem- brane, muscle, and superficial parts removed, so that nothing is left but the two cartilages surrounding the opening, and a canula inserted a few days before evulsion is attempted. When all disposition to haemorrhagic oozing has ceased, and all tenderness disappeared, the canula should be taken out, the chin thrown well back, so as to enlarge the crico-thyroid space as much as possible, and a careful examination made with one of Neudorfer's infra-glottic mirrors, to ascertain the exact origin of the growth. The mirror must then be 104 On Grozvths in the Larynx. dispensed with, and the growth removed with short tube- forceps. This operation can only be performed where the crico- thyroid membrane is of average size, and if there is not room to effect removal, tracheotomy should be performed in the first instance instead of laryngotomy. The steps of the operation are almost the same as in (crico-thyroid) laryngo- tomy. When the patient has recovered from the tracheotomy, that is to say, a few days after the operation, the canula should be removed, and an attempt made to extirpate the growth. In carrying out the operations, the two sides of the windpipe require to be held back with retractors, in order that instruments may be conveniently passed into the larynx. The patient should continue to wear the canula for a few months, or, at any rate, for a few weeks, in case eradication be incomplete, or recurrence take place. Had Dr. Burow taken this precaution, the result of his case would have been even more satisfactory. Comparative Merits of Operation.—It is very remarkable that this operation has not been more frequently performed. In my 100 tabulated cases the growth was situated ten times below the vocal cords. In three of these cases evulsion was effected with great difficulty, and only after several months' close attendance. In two of them, indeed, the suc- cess was incomplete, a small portion of the growth remain- ing, and the voice being still a little hoarse. In the cases tabulated in Appendix D, the growths were in 15 cases situated below the vocal cords. In five of these thyrotomy was performed, and in two the less serious step of tracheo- tomy was necessitated, before the growth could be removed through the fauces. There is little reason to doubt that, in many, if not all, of these cases, had an opening been made in the crico-thyroid membrane, the treatment might have been reduced to a few days, or at the most a few weeks, instead of lasting, as it did, several months, and that it is possible the results would have been altogether more satisfactory. Nevertheless, it must not be forgotten that many patients would prefer a tedious operation, carried Treatment—Combined Method. 105 out per z'ias naturalcs, to a direct incision through the neck, however slight the operation may be. In one of my cases the operation through the crico-thyroid membrane was sug- gested by me, but declined by the patient. Although there is a much greater prospect of success if a canula is employed, as advised above, the contingent danger of subsequent bron- chitis is probably greatly reduced by dispensing with it, after the manner of Dr. Burow. The Combined Method of Removing Growths - (Tracheotomy or Laryngotomy being first performed, and the growth being subse- quently removed by laryngoscopy). This method of treatment may be advantageously carried out in those cases in which the size of the growth causes immediate danger to life, and where laryngoscopic treatment gives rise to serious dyspnoea. It has already been remarked that operative procedures on large growths are apt to give rise to inflammatory tumefaction of the mucous membrane and to spasm of the glottis ; and in three cases which have come under my notice, partial evul- sion, or attempts, at evulsion, through the upper orifice, have precipitated tracheotomy. In these cases it would perhaps have been as well to have opened the wind- pipe in the first instance, and only subsequently to have attempted removal through the mouth. Where the combined method of treatment is adopted, the patient should be allowed a few days' rest after tracheotomy has been per- formed, and only when thoroughly recovered from the operation, should eradication be attempted, with the aid of the laryngoscope. The practitioner will be guided by the observations already made under the sub-sections on Mechanical Treatment and Chemical Treatment, as to the best method of removing or destroying the neoplasm, and only when the growth is completely eradicated should the canula be removed. io6 On Growths in the Larynx. This method of treatment holds a middle place between laryngoscopic and extra-laryngeal treatment, and while on the one hand the practitioner should always first endeavour to remove a growth through the fauces, it is better, if he does not succeed, to adopt the operation of tracheotomy as a safeguard, and then to pursue laryngoscopic treatment. If then he is still unable to remove the growth through the mouth, he may proceed to the more serious operation of thyrotomy. In my own practice I have successfully em- ployed the combined treatment in two cases.1 In two others,2 it became necessary to perform tracheotomy, on account of the difficulty of removing the growth per vias naturales, and the respiration being relieved by this operation, no further treatment of the neoplasm was permitted. The combined method has been frequently pursued on the Continent and in America, and 11 cases are contained in Appendix D. Of these, 5 were cured, and in the remaining 6 the dyspnoea was entirely relieved and the voice improved. It will thus be seen that the combined method offers very satisfactory prospects. 1 Appendices A and C, Cases 74 and 88. 2 Appendices A and C, Cases 36 and 45. APPENDIX A. REPORTS OF ONE HUNDRED CONSECUTIVE CASES TREATED BY THE AUTHOR. 15 APPENDIX A. Cask I.—{Papillomatous) Growth on the under Surface of Epiglottis; Irregular Ulceration of the edges of the Vocal Cords ; Treatment by Caustic. Solutions ; Improvement. Mr. W., of Sligo, a bookseller, aged about 45, consulted me in June, 1862, for loss of voice, which had existed since November, 1859. On examining the throat with the laryngoscope, the vocal cords were seen to be of a dirty grey colour, and in a highly dis- organized state,— their edges being serrated in a very peculiar manner; the rough toothlike processes of one vocal cord fitted into corresponding depressions in the edge of its fellow. In the middle of the under surface, and near the edge of the epiglottis, was a small round excrescence (Eig. 9). There was nothing of a Fig. 9. syphilitic character in this case ; and the diseased condition of the larynx seems to have originated in a severe and prolonged catarrh. In this case, I enjoyed the advantage of a consulta- tion with Professor Czermak. He agreed with me in thinking it a very unfavourable one for treatment,—at least as regarded the condition of the vocal cords. He also concurred with me in re- commending the local application of strong solutions of nitrate of silver. Neither of us, however, was at all sanguine as to the effect it might produce. I applied this remedy to the interior of the larynx eight or nine times, but without any apparent effect. Mr. \V. no On Grozvths in the Larynx. then returned to Ireland, and the same treatment was continued by Dr. Wood, of Sligo. After many months' treatment, the whisper was replaced by a very gruff voice ; and when Mr. W. came over to consult me in September, 1863, the edges of the vocal cords were much more even,—the right cord being almost smooth, and the voice, though rather hoarse, was distinctly phonetic. The small warty growth had slightly diminished in size.— The Use of the Laryngoscope, second edition, 1866, page 86, and facksonian Prize Essay, On Diseases of the Larynx, crc, 1863, Case 20. MS. in Library of the Royal College of Surgeons. Case II.—{Papillomatous) Excrescences on the Right Ary-epiglottic Fold and Ventricular Band; Treatment by Caustic Solutions; Improvement. C A., aet. 42, from Diss, in Norfolk, applied at the Hospital for Diseases of the Throat, in April, 1863. This patient was the mother of a large healthy family. She had suffered from loss of voice and a constant inclination to clear the throat for two years, but was otherwise quite well ; she attributed the aphonia to having taken cold. With the laryngoscope, the aphonia was seen to depend on the presence of numerous small warty growths, situated on the right ary-epiglottic fold and ventricular band. There was also slight congestion of the vocal cords (Fig. 10). Under Fig. 10. the use of solutions of nitrate of silver (5ij ad 3j), applied very frequently for some weeks, this patient became able to speak in a fairly loud, though still rather harsh, voice. When the patient was obliged to return to the country, the greater part of the excres- cence had been destroyed, but a small portion still remained on the ventricular band.—The Use of the Laryngoscope, second edition, page 87, and fachsouian Prize Essay, 1863, Case 19. ioo Consecutive Cases treated by the Author. in Case III.—Five large Papillomatous Excrescences in the Interior of the Larynx; Treatment by Evulsion and Escharotics; Cure. William W., set. 44, carpenter, applied to me April 10th, 1863, on account of loss of voice. He stated that his general health was very good, but that three years ago he had caught a cold and bad sore throat, and since then he had not been able to speak a word out loud. At Christmas his breathing was much affected, and he thought he should have been suffocated; but the attack passed off, and he said that, with the exception of not being able to speak out loud, he was now quite well. He had never had syphilis. On making a laryngoscopic examination, the laryngeal mucous mem- brane, above and below the vocal cords, was seen to be covered with dark, reddish, spongy excrescences (Fig. 11, and Plate II. ^g- 3)- Gne was situated on the right side of the under surface of the epiglottis; another involved the whole right ventricular band; a third covered the whole of the right vocal cord ; a fourth occupied half of the left ventricular band ; and a fifth the anterior half of the left vocal cord. Below the right vocal cord a number of smaller excrescences were also seen extending down into the trachea. Fig. 11. This case was seen by Drs. Czermak, Frodsham, George Johnson, Wahltuch, and others. With my laryngeal forceps, I succeeded, in a number of sittings, in removing, in small fragments, the whole of the four upper excrescences. This included the one seated on the left vocal cord. These fragments were kindly examined for me by Dr. Andrew Clark. He "found them to consist of numerous vellowish, hard, nodular, or warty-looking particles. Under the microscope, some of these masses consisted entirely of enlarged racemose glands, clothed with many layers of epithelium, the outer- most layer of which was in a state of partial desquamation. A few of the papilke were either quite hollow, or had contained fluid." He H2 On Grozvths in the Larynx. regarded the case as one of " Granular Wart." The small particles which were torn away with the forceps produced so little effect on the bulk of the large growth on the right vocal cord, that I was induced to try the effect of escharotics. Nitric acid and chromic acid were both applied several times with decided advantage ; but the greatest benefit resulted from the employment of a mixture of caustic soda and lime. In August, the patient recovered a loud and tolerably clear voice. This patient remained under observation until November, 1866, when all the growth had been removed and the voice completely restored.—The Use of the Laryngoscope, second edition, page 121, and facksonian Prize Essay, 1863, Case 21. This patient returned to the Hospital, March 7th, 1870, stating that since his discharge in 1863, his voice had remained perfectly clear till about four months previous to his present application. It was now gruff and husky. On laryngoscopic examination, the larynx was seen to be almost entirely occupied by two symmetrical growths of a pink colour and irregular surface, proceeding from each ventricular band. So large were the growths, that, in attempted phonation, they met in the median line, and only the posterior half of the vocal cords was then visible. The case was seen before treatment by Dr. Carpenter, F. R.S., and during his attendance by Dr. Stage, of Copenhagen, and Mr. Keene. In four sittings, the larynx was entirely cleared, and the voice restored to its normal tone. Case IV.—(Papillomatous) Excrescences on and beneath both Vocal Cords; Treatment by Evulsion ; Cure. Mrs. A., aet. 35, die wife of a mechanic, applied at the Hospital for Diseases of the Throat in April, 1863, though, in consequence of my absence from town, she did not come under my care till the following month. I had previously (in December, 1862) seen the patient, at Mr. Maunder's request, in conjunction with Dr. Gibb ; and the latter author has referred to the case {Diseases of the Throat, page 156. London, 1864) and given a rough sketch of the laryngo- scopic appearance. The patient stated that she caught cold in 1859, was very hoarse for two years, and that in 1861 her voice had become quite suppressed. For the last two years she had always spoken in a whisper. There was no history nor symptom 100 Consecutive Cases treated by the Author. 113 of syphilis or phthisis. With the laryngoscope, both vocal cords were seen to be of a dirty greyish colour, and in an irregular papillomatous condition : the appearance is shown in Fig. 12. Fig. 12. Subsequently I discovered two growths,—one below each vocal cord. As the diseased condition of the cords was so general, and the growths on the cords were so imperfectly developed, I thought that it would be best to treat the case with caustics. Strong solutions of nitrate of silver were accordingly applied, but they produced so much dyspnoea, that the treatment was obliged to be discontinued. Under these circumstances, I tried to use forceps; but the patient being unable to open her mouth widely, the laryngeal aperture being exceedingly small, and the growths on the vocal cords most minute, great difficulty was experienced, and it was only after repeated failures that I ultimately succeeded in clearing the vocal cords of the warty growths which covered them. The growths below the cords, which afterwards became distinctly visible, being of larger size, were removed with much less difficulty. A month after the removal of the last growth, the patient's voice was completely restored. T have not seen her now for some time, but I received a note (dated October 31st, 1864) from Mr. Brown, of Finsbury Circus, who sent the patient to me, in which he says, " I called on Mrs. A. this evening, and am pleased to find her voice is entirely restored by your treatment."—The Use of the Laryngoscope, second edition, page 124, and facksonian Prize Essay, 1863, Case 26. Case V.—Papillomatous Grozoth on the Left Vocal Cord; Treatment by Evulsion; Cure. Henry R., aet. 45, a gas-fitter, applied at the Hospital for Diseases of the Throat, May ist, 1863, on account of loss of voice of nine years' standing. He stated that he had attended at various metropolitan hospitals, and had lately been at the ii4 On Growths in the Larynx. Brompton Hospital. On examining his throat with the laryngo- scope, a small round excrescence, about the size of a pea, was seen on the left vocal cord. The warty growth was situated on the free edge, and exactly in the middle of the cord, and on attempted phonation it was seen that, owing to the projection of the growth, the cords could not become approximated. On the right cord, exactly opposite to the wart on the left cord, there was a distinct round indentation. The laryngoscopic appearance is seen in Fig. 13. I had the opportunity of exhibiting this patient to Drs. Czermak; Wahltuch, and others. There was some difficulty in removing this growth, owing to its small size, and the more than usual awkwardness of the patient, and it was not till the fourth sitting that it was successfully seized and removed. It may be remarked, that solid nitrate of silver had been previously, repeatedly applied, but without benefit. Dr. Andrew Clark examined micro- scopically the portions removed with the forceps, and the following was his report:—" The growth was found to consist of two sets of particles, one membranous, the other warty or obscurely papilliform. The membranous portions consisted of from twenty to thirty layers of scaly epithelium, surrounded and penetrated by a confervoid growth. The epithelial cells composing the layers were polygonal, flattened, nucleated, and easily affected by weak alkalis and acids. The nucleus of each cell was oval, abruptly defined, rather large in proportion to the containing cell, in most cases surrounded by a clear halo, and in some showing signs of division. The papillary portions consisted of simple outgrowths of nucleated connective tissue and rudely-formed blood-vessels, clothed with numerous layers of scaly epithelium, similar to those already described. Some of the papillae exhibited large vacuoles or spaces filled with colloid matter, which, in one or two instances, had burst through the cover- ing epithelium." Dr. Clark considered the tumour to be a true wart. Immediately after the operation the patient spat up a few 100 Consecutive Cases treated by the Author. 115 teaspoonfuls of blood, and the same day he was able to sound his voice. The next day he complained of a feeling of great soreness, and there was so much involuntary objection to a laryngoscopic examination, that I was unable to see exactly how the wound looked. Nine days later, however, the mucous membrane over the left vocal cord, where the growth had been, looked rather puckered, and the depression on the right cord was still visible. At the end of a month the voice was perfect, and all morbid appearance in the larynx, including the little pit on the edge of the right cord, had completely disappeared.—The Use of the Laryngoscope, second edition, page 125, and facksonian Prize Essay, 1863, Case 22. Case VI.—{Papillomatous) Growths on both Vocal Cords; Treatment by Evulsion ; Cure. William J., aet. 40, applied to me in May, 1863, on account of hoarseness of five years' standing. His general health was good, but fifteen years before he had a primary venereal sore. He had never suffered from any secondary symptoms. The voice was harsh, but not suppressed; and with the laryngoscope a large, thin, flat, membranous growth was seen to project horizontally from each vocal cord, and to meet in the centre. On account of the pendulous condition of the epiglottis, it was difficult to get an extensive view of the larynx, and consequently the growths could not be seen in their entirety. The appearance is shown in Fig. 14. The smallness Fig. 14. of the laryngeal aperture was still more inconvenient in operating ; and it was only after several unsuccessful attempts that I managed to remove a small portion of the growth on the right vocal cord. Under these circumstances, I endeavoured to divide the left growth through its base, with my laryngeal lancet. After the operation, the patient left me, but soon returned, spitting up considerable quan- tities of blood. On examination with the laryngoscope, the mucous 16 u6 On Grozuths in the Larynx. membrane was seen to be covered with blood ; but the exact source of the haemorrhage could not be ascertained. I applied a strong solution of perchloride of iron to the interior of the larynx, and directed the patient to suck ice. The haemorrhage, however, which continued for some time—to an extent that was really alarming,— was ultimately arrested by.the patient gargling with, and swallowing, a saturated solution of tannin. The first mouthful of the tannin that was swallowed stopped the bleeding entirely. A day or two after the operation, a careful examination of the larynx was made both by Dr. George Johnson and myself, but we were neither of us able to ascertain the source of the haemorrhage. I have since removed several fragments by using the horizontal blades of my tube-forceps, and the patient's voice is now clear ; he still complains, however, of a slight tickling in the throat.— The Use of the Laryn- goscope, second edition, page 126, and Jdiksonian Prize Essay, 1863, Case 23. Case VII.—Fibrous Grozvth above the Anterior Commissure; Treatment by Evulsion ; Cure. Morris B., set. 41, shoemaker, and formerly singer, applied at the Hospital for Diseases of the Throat, August 20th, 1863. He stated that he had been extremely hoarse for seven years, but had never suffered from complete loss of voice. He had been affected with primary syphilis when he was sixteen. A physician had recommended him to have his uvula removed, but the operation had not improved his voice. A laryngoscopic examination showed that there was a yellowish-pink growth, about the size of a small bean, just above the anterior insertion of the vocal cords. It was moveable (and there- fore probably pedunculated), but the base was hidden by the tumour, and therefore its exact origin could not be ascertained. When the glottis was closed, the growth rested on the extremities of both the Fig. 15. cords, sometimes, however, lying more on the right, and some- times on the left cord. The appearance is shown in Fig. 15. 100 Consecutive Cases treated by the Author. 117 Aug. 21.—I had the advantage of a consultation with Dr. George Johnson and Mr. Mason, who entirely concurred in my diagnosis. Aug. 24.—In the presence of these two gentlemen, I removed the excrescence with my tube-forceps. The growth was success- fully seized at the first trial, and all of it, except a small portion of its base, was brought away. After the operation, we examined the patient with the mirror, and the base of the growth covered with blood was indistinctly seen. I was disposed to remove this small remaining fragment, but after a consultation, it was thought better to leave it alone, under the idea that it would probably wither away. Immediately after the operation, Dr. Johnson thought he noticed an improvement in the voice. Aug. 26.—There being still a small portion of the base of the growth remaining, I removed it with tube-forceps. The patient was completely cured, and at the end of a fortnight he spoke per- fectly well. " The morbid growths," according to Dr. Andrew Clark, " con- sisted of three or four minute, shapeless pieces of yellowish colour, streaked with red, and of a horny consistence. On account of their hardness, their structure could not be very easily determined. On the free surface, however, were several layers of thin, scaly epithe- lium, few of the elements of which exhibited any nuclei. In fact, but for the absence of cholesterine, the cell-elements might have been most readily mistaken for those of cholesteatoma. Beneath the epithelial coverings were minute extravasations of blood, and amorphous masses of a coagulated proteine compound." Though in this case the proteine compound had not developed fibres, the case was regarded by Dr. Clark as one of commencing " Fibro- epithelial Growth."—The Use of the Laryngoscope, second edition, page 128, and facksonian Prize Essay, 1863, Case 25. Case VIII.—{Papillomatous) Grozvths on the Epiglottis and Right Ventricular Band; Treatment by Evulsion ; Cure; Subsequent Recurrence; Treatment by the same method; and Complete Restora- tion of Voice. George T., aet. 26, a sailor, applied at the Hospital for Diseases of the Throat, January 28th, 1864, on account of slight dysphagia, from which he had suffered for six months. He had lately returned from Hobart Town, and on his voyage round Cape Horn, had been n8 On Grozvths in the Larynx. exposed to severe cold during his night watches; since that time he had suffered from hoarseness. On laryngoscopic examination, two small excrescences were seen to be sprouting from the under surface of the epiglottis, and one large foliate growth from the right ventri- cular band (Fig. 16). Fig. 16. These growths were removed, without much difficulty, in five sittings, partly with common laryngeal forceps, and partly with tube-forceps ; and both the dysphagia and hoarseness were entirely relieved. The patient was seen both before and after treatment by my colleague, Mr. George Evans. The man applied again at the Hospital, February 21st, 1866, stating that he had been three voyages since his former attendance, and that it was only during the last that he had suffered from his old symptoms. For a month his voice had been completely sup- pressed, and he had been hardly able to do any work of an active character, on account of attacks of shortness of breath, amounting almost to suffocation, which supervened on the slightest exertion. On laryngoscopic examination, irregular warty excrescences were discovered beneath the anterior commissure of the vocal cords. There was no appearance of recurrence in the situation of the former growths. The whole of the new formations were removed with tube-forceps, after an attendance of three months. The case was seen during this second course of treatment by Drs. Tatham, Thurgar, and Wilkins. On microscopic examination the growths were found to be of a papillary structure, in which the connective-tissue element could not be detected. The laminae of epithelium were very abundant, twenty-eight layers having been counted in one part. 100 Consecutive Cases treated by the Author. 119 Case IX.—Benign Epithelial Growth on the Right Vocal Cord; Partial Evulsion ; Great Improvement. Mrs. S., aet. 45, a married lady, residing in Manchester, consulted me in January, 1864, on account of great dyspnoea and loss of voice. The symptoms had been coming on during the previous three years, but the dyspnoea had become much more severe during the last six months ; and whilst for the first two years she had been able to speak in a hoarse voice, during the last twelve months she could only whisper. On making a laryngoscopic examination, a cauliflower-looking growth, about the size of a large pea, was found occupying the anterior third of the right vocal cord. An attempt was made with tube-forceps to remove the growth, but it caused so much spasm that it was found necessary to desist. A week later, a large piece—rather more than half the entire growth—was removed. On the 14th of February another smaller piece was removed in the same way. After this, there was no further dyspnoea, and the voice very much improved. The portions removed were examined by Dr. Andrew Clark, and found to consist almost entirely of epithelial scales, in various stages of growth, with a very small amount of connective tissue at what appeared to be the base of the tumour. Case X.—{Papillomatous) Grozoths on both Vocal Cords; Treatment by Evulsion ; Cure. Miss Mary B., aet. 30, was sent to me by Mr. Parsons, of Bridgewater, April 7th, 1864. This patient lived in London, and after she had been suffering from loss of voice for some months, a distinguished physician recommended " change of air to her native place." On arriving there (Bridgewater) she was recom- mended to return back to London to see me, and the laryngoscope at once revealed the cause of the hoarseness. A small growth was seen on the right vocal cord, and afterwards, when the patient had been examined once or twice, another growth was perceived on the left cord, near to its anterior insertion. The 120 On Growths in the Larynx. appearance is shown in Fig. 17. The history of the case seemed to show that these growths originated in chronic laryngitis. After Fig. 17. twenty attempts, only four of which were successful, the growths were entirely removed with the forceps. After the removal of the warts from the vocal cords, a small growth was seen lower down ; but as the voice was restored, no further treatment was adopted.— The Use of the Laryngoscope, second edition, page 130. Case XI.—Papillary Grozvths above and below the Anterior Com- missure of the Vocal Cords; Treatment by Evulsion ; Cure. Caroline M., aet. 4, who for two years had been suffering from loss of voice, stridulous breathing, and occasional attacks of suffo- cation, was placed under my care, at the Hospital for Diseases of the Throat, November 9th, 1864. The symptoms had come on two years previously, but had lately become much aggravated. On examining the patient with the laryngoscope, an oblong tumour, about three-eighths of an inch long, and a quarter of an inch broad, was seen to be attached just above the interior in- sertion of the vocal cords. A consultation having taken place with Mr. Mason, who also examined the child with the laryngoscope, I removed the growth with the tube-forceps. After its evulsion, numerous excrescences were seen below the anterior insertion of the vocal cords. These, after several operations, were also removed. The respiration became easy as soon as the large growth was removed, but it was not until the smaller ones were eradicated that the voice was restored. The portions removed were found to be of simple papillary structure.—Transactions of the Pathological Society, vol. xvi. page 38 ; also, The Use of the Laryngoscope, second edition, page 133. IOO Consecutive Cases treated by the Author. 121 Case XII.—Numerous Papillomatous Grozvths on the Vocal Cords and Ventricular Bauds ; Treatment by Evulsion ; Cure. Ellen B., aet. 6, was brought to me at the Hospital for Diseases of the Throat, November 20th, 1864, on account of loss of voice, which had existed for two years. The patient had been under the care of several medical practitioners, and among others, under that of Dr. Martyn, of Knightsbridge, who had used the laryngoscope and recognized the nature of the disease. Finding numerous excrescences on the vocal cords and ventricular bands (Fig. 18), before operating I had a consultation with Mr. Mason. Notwithstanding the early age of the patient, the growths were easily removed with tube-forceps, and the voice immediately became phonetic; for a long time, however, the little girl remained slightly hoarse. On microscopic examination, the growths were found to consist of several layers of squamous epithelium, a few papillae, and some enlarged racemose glands.—-Transactions of the Pathological Society, vol. xvi. page 39 ; and The Use of the Laryngoscope, second edition, page 133. Case XIII.—Small {Papillomatous) Growth on the Cartilaginous portion of the Glottis on Right Side; Treatment by Evulsion ; Cure. Harriett H., a fish-hawker, aet. 28, applied at the Hospital for Diseases of the Throat, in January, 1865, on account of a constant tickling in the throat, which caused her great uneasiness, and even anxiety. She had a frequent inclination to clear the throat; but, not- withstanding that her occupation required the constant use of her voice at a high pitch, she was not at all hoarse. On making an examination, the pharynx was seen to be con- siderably relaxed, and the uvula somewhat elongated. Without further examination, this might have seemed sufficient to account for her symptoms ; but with the laryngoscope, a small warty growth was at once discovered on the posterior, or cartilaginous portion of the I 22 On Grozvths in the Larynx. right vocal cord (Fig. 19). The growth appeared to prevent the approximation of the cartilaginous portion of the glottis, but did Fig. 19. not at all interfere with the production of sound. The patient was treated for pharyngeal relaxation, and a portion of the uvula was removed ; but at the end of six weeks, the troublesome symptoms not being at all relieved, treatment was directed to the removal of the growth by the common antero-posterior forceps. After a few sittings the little wart was removed in the presence of Dr. Mill Frodsham, and the cough entirely ceased a week later. The patient was seen in July, 1865, when she still remained quite well. This case is one of unusual interest, both in its clinical and its physiological bearings. It shows, in the first place, that a combina- tion of symptoms indicative of pharyngeal disease may depend on a morbid condition of the larynx; and, secondly, it demonstrates conclusively, that the closure of the posterior part of the glottis is not essential to the production of sound. Case XIV.—Numerous s?nall Benign Epithelial Excrescences on both Vocal Cords and the Right Ventricular Band ; Partial Evulsion ; Improvement. J. C, aet. 46, hawker, applied at the Hospital for Diseases of the Throat in the latter part of January, 1865, on account of aphonia. He had been hoarse for eighteen months, but the voice had only been entirely suppressed for the last seven weeks. He attributed his affection to his having been obliged to exert his voice while suffering from cold. On laryngoscopic examination, the right ventricular band and both vocal cords were seen to be covered with short, sessile, foliate, excrescences of a pinkish colour. The larynx was generally much congested. Inhalations of compound tincture of benzoin were ordered; and at the third visit, on the 14th of February, several ioo Consecutive Cases treated by the Author. 123 small portions of the growths were removed with common laryngeal forceps. Microscopic examination, kindly conducted by Dr. Andrew Clark, showed the growths to be of a " simple warty character." No papillary structure could be found. On two subsequent occasions small portions were removed, and a fairly useful voice was restored. Content with this improvement, the patient discontinued his visits. When last seen, a small portion of growth still remained on the left vocal cord. Case XV.—Papillary Growth on the Right Vocal Cord; Treatment by Evulsion ; Cure. Conway C, aet. 12, from Gosport, was brought to me in January, 1865, on account of loss of voice and dyspnoea. When five years old the boy had suffered from croup after measles, and since then had not been able to speak out loud. For the last eighteen months he had been short of breath, having been quite unable to play at any games, and several times during the last year he had "seemed as if he would be strangled." On making a laryngoscopic examination, a growth was seen attached to the right vocal cord and beneath the anterior commissure. The appearance is shown in the annexed woodcut (Fig. 20). On February 3rd Mr. Mason kindly made a very Fig. 20. careful laryngoscopic examination and drawing of the case. After a great many attempts I ultimately succeeded with my tube-forceps in removing the whole of the growth ; and in the following June, to use Mr. Mason's expression, there was nothing to see but " a slightly uneven condition of the cords :" this afterwards passed away. Dr. Andrew Clark described the specimens which were brought before the Pathological Society, December 19, 1865, as being " examples of simple papillary, warty, or cauliflower growths." The voice was completely restored.— The Use of the Laryngoscope, second edition, page 133. 17 124 On Growths in the Larynx. Case XVI.—Fibrous Growth on the Posterior Wall of the Larynx ; Treatment by Evulsion; Recovery of Speaking Voice, but not of Power of Singing. George S., aet. 37, a vocalist, applied at the Hospital for Diseases of the Throat, May 10th, T865, on account of hoarseness, which had existed for two years and a half, but had not much increased since its first appearance. There had been no cough nor other symptom. On laryngoscopic examination, a large pyramidal growth, of a dark-red colour, was seen projecting from the posterior wall of the larynx, between the arytenoid cartilages, into the area of the glottis. The vocal cords were much congested (Fig. 21). Fig. 21. The growth was easily removed with tube-forceps at the first attempt, in the presence of Drs. Dale, Frodsham, and others. A month later the patient's speaking voice was perfectly restored, but the power of singing had not returned three months after the removal of the growth. There also still remained considerable congestion of the mucous membrane of the larynx. On micro- scopic examination the growth was seen to be a true fibroma. Case XVII.—Large Benign Epithelial Growth attached to the Left Vocal Cord; Treatment by Evulsion ; Cure. Eliza P., aet. 31, a stout healthy-looking woman, from Gravesend, was sent to me in June, 1865, by Mr. John A. Kingdon. She stated that in the winter of 1858-59 she had a bad cough and cold, and that the hoarseness which came on at that time passed in a few months into complete loss of voice; since then she had not been able to speak a word out loud. In i860 she was an in-patient in a provincial hospital, and there shower-baths were used—but in 100 Consecutive Cases treated by the Author. 125 vain—to restore the voice. In the following year she was admitted into one of the metropolitan hospitals, and here the treatment con- sisted in blistering the neck, twenty-seven blisters having been applied consecutively; afterwards iodine, mustard poultices, and turpentine stupes were used, and general remedies (quinine, iron, &c), but all without effect. She further stated that she always suffered now from shortness of breath, and that lately she had had two attacks of great difficulty of breathing, which had lasted for several days. On makiug a laryngoscopic examination, an irregular lobulated growth, about the size of a sparrow's egg, was seen to be attached to the entire length of the left vocal cord; it projected up into the laryngeal cavity, and across the glottis. At the patient's second visit an attempt was made to seize the growth with tube- forceps, and on the first trial a large piece was seized and brought away. On several other occasions fragments were removed, but the attempts to seize the tumour were frequently quite unsuccess- ful. On account of the distance at which the patient lived, she was not able to attend at all regularly; and long intervals often intervened between her visits. Accordingly, it was not till March 7, 1866, that I succeeded with a pair of ordinary forceps (opening in the antero-posterior direction) in completely clearing the larynx. Dr. Pratt was present on this occasion, and made a laryngoscopic examination both before aud after the removal of the last piece. The patient attended twice at the hospital afterwards, and the larynx was seen to be perfectly healthy. The voice was clear and natural. A portion of the growth examined by Dr. Andrew Clark was pro- nounced to be " an ordinary warty growth."—The Use of the Laryngoscope, second edition, page 134. Case XVIII.—Papillary Grozoth on the Right Vocal Cord; Dysphonia ; Treatment by Evulsion ; Cure. George D., aet. 47, an engine-driver, applied at the Hospital for Diseases of the Throat, July 5th, 1865, on account of hoarseness. This symptom had come on gradually for about a year; and when he applied, his voice was so hoarse as to be barely phonetic. On laryngoscopic examination, a pink cauliflower-like excrescence was seen occupying the middle third of the edge of the right vocal cord (Fig. 22, and Plate II. fig. 2). The whole of the growth was re- moved in two operations, but the voice was not completely restored 126 On Growths in the Larynx. till December, when the patient was examined, and no trace of the growth could be found. In this case, the larynx was examined, Fig. 22. both before and after operation, by my colleague, Mr. George Evans. The growth was found, on microscopic examination, to consist of branching papillae. Case XIX.—{Fibroma) on the Epiglottis; Evulsion; Negative Result. J. B., aet. 34, a mechanic, came from the neighbourhood of Leeds, to consult me in July, 1865, on account of hoarseness, of two years' standing. During the last few weeks caustic solutions had been applied to the larynx by a local practitioner, but without benefit. On laryngoscopic examination, a polypoid excrescence, of pink colour and smooth surface, was seen covering the anterior third of the right vocal cord, though growing from the lower part of the epiglottis, by a broad base. From its smooth appearance, it was judged to be a fibroma (Fig. 23). Two attempts were made to Fig. 23. remove the growth with the tube-forceps ; but the patient was so nervous, and his throat so irritable, that the growth could not be seized. The patient left London again the same day, and was not seen subsequently. 100 Cofisecutive Cases treated by the Author. 127 Case XX.—{Papillomata) on both Vocal Cords; almost complete Evulsion; Great Improvement. John E., aet. 35, labourer, came from Walton-on-Thames to the Hospital for Diseases of the Throat, September 16th, 1865. The only symptom complained of was loss of voice. Hoarseness had existed for two years, and had gradually increased, until, for the last few months, the voice had been entirely suppressed. On laryn- goscopic examination, a small irregular growth was seen occupying the anterior two-thirds of the right vocal cord, and another larger one on the posterior two-thirds of the left vocal cord (Fig. 24). Fig. 24. The latter growth projected within the larynx, so as to very much diminish the size of the glottis. Notwithstanding this, the patient had never suffered from dyspnoea, nor had his general health been at all impaired. The whole of the growth on the left vocal cord was removed, and a large portion of that on the right cord was removed in the presence of Dr. Baxter, and Dr. Clark of Melbourne. A small piece of the latter, however, remained near the anterior insertion of the cord. The voice, although still gruff, was phonetic and powerful, and the patient discontinued attendance. Case XXI.—Two very Small Papillomata on the Right Vocal Cord; Treatnient by Evulsion ; Cure. Samuel J., aet. 36, tailor, applied at the Hospital for Diseases of the Throat, in December, 1865, on account of dyspnoea and hoarse- ness. The attacks of shortness of breath came on suddenly, and generally at night; but they sometimes occurred during the day. The first attack had come on eighteen months previously, and the second one six months later. During the last year the attacks had been much more frequent. They usually occurred about three o'clock in the morning, and lasted for an hour, or an hour and a half. 128 On Grozvths in the Larynx. They appeared to be of a distinctly asthmatic character, and often commenced with a stinging sensation in the throat, and with cough- ing. The patient had been hoarse for about six months. The impaired respiration was attributed to asthma, and the patient had previously been unsuccessfully treated for that complaint for some months. A laryngoscopic examination showed two very small growths attached to the edge of the anterior half of the right vocal cord (Fig. 25). The more anterior growth was removed at the second Fig- 25. visit, but it was not till March, 1866, and after a great number of unsuccessful attempts, that the smaller growth was seized. In May the voice was perfectly clear, and he had had no return of dyspnoea since February 28th. Dr. Langmaid, of Boston, U.S.A., was present at the removal of the first growth, and this very interesting case was seen by Drs. Tatham, Lanchester, and several other gentlemen, during the time it was under treatment. (The patient applied a year later at the hospital on account of a slight catarrh: he stated that he had had no return of his former symptoms, and the larynx was seen to be quite free from any recurrence of the growths.) Case XXII.—Large Papillary Growth on the Left Vocal Cord; Partial Evulsion ; Great Improvement. Eliza W., aet. 45, applied at the Hospital for Diseases of the Throat, January 18th, 1866, on account of complete loss of voice and slight shortness of breath. She stated that for the last twenty- five years she had been hoarse, and that for the last eight her voice had gone altogether ; latterly, she had occasionally suffered from distressing attacks of suffocation. She had been treated by external galvanism, and had been severely blistered on the neck, but without benefit. 100 Consecutive Cases treated by the Author. 129 On examination with the laryngoscope, a large excrescence was seen occupying the space between the vocal cords. The exact origin could not be made out, but it appeared to grow from the anterior third of the left vocal cord, and occupied the anterior three-fourths of the glottis (Fig. 26). Fig. 26. The upper opening of the larynx was rather small, and in other respects the case was a difficult one for operative manipulation. Under these circumstances, I was unable to use forceps ; but with a very simple instrument of my own contrivance—a piece of rigid wire bent at a suitable angle, and terminating in a loop—I succeeded in extirpating the principal portion of the growth. Dr. Andrew Clark, who had made a careful microscopic examina- tion of the specimen, described it as " highly developed, typical, epithelial cancer—pathologically speaking, the most malignant variety he had ever seen, of any small growth in that locality." The clinical history of the case did not, however, correspond with the histological deductions : the long time (twenty-five years) that the tumour, or, more correctly speaking, its symptoms, had been in existence, and the total absence of cachexia, indicated a growth of more benign character. There is a portion of the growth still (Feb. 20th, 1866) in the larynx, but the symptoms are greatly alleviated; the voice, instead of being completely suppressed, is now only hoarse, and the respiration is not in the least embarrassed.—Transactions of the Pathological Society, vol. xvii. page 33. Case XXIIL—(Papillomatous) Growths on the Left Vocal Cord and on both Ventricular Bands; Evulsion of a Large Portion; no Lmprovemcnt in Voice. Thomas L., aet. 34, coachman, applied at the Hospital for Diseases of the Throat, in January, 1866, on account of aphonia of two years' standing. On laryngoscopic examination, finely-divided excrescences 130 On Growths in the Larynx. were seen on the left vocal cord and on both ventricular bands, and two nearly smooth, red, mammillary warts on the right vocal cord. The portion of the left vocal cord not covered by growth was considerably congested (Fig. 27, and Plate II. fig. 1). Many small Fig. 27. fragments were removed with the tube-forceps, and the most anterior wart on the right vocal cord was divided at its origin with the laryngeal lancet. The patient discontinued attendance after six months, there being but little improvement in the voice. A portion of the warts still remained both on the right ventricular band and on the left vocal cord. Case XXIV.—{Papillary) Growth beneath the Anterior Commissure of Vocal Cords; Treatment by Evulsion; Cure. Fanny H., aet. 24, a housemaid, attended as an out-patient at the Hospital for Diseases of the Throat, between the months of Feb- ruary and May, 1866, during which time she was frequently seen by Drs. Tatham and Truell, and Mr. Wilkins. The patient spoke in a husky voice, and stated that she had been hoarse for eighteen months, that frequently the voice was suddenly lost altogether, and that twice she had had attacks of suffocation. She also suffered at times from a severe paroxysmal cough. On laryngoscopic examination, a small pendulous growth was seen beneath the anterior commissure of the vocal cords. On Fig. 28. Fig. 29. inspiration (Fig. 28) the polypus appeared comparatively small, and quite free of the vocal cords ; on phonation it was almost invisible; and on forced expiration (Fig. 29) it rose above the IOO Consecutive Cases treated by the Author. 131 level of the cords. It was probable, therefore, that the tumour always prevented the perfect approximation of the cords, thus causing hoarseness; but that it was only when it was coughed up, and so became impacted in the glottis, that the aphonia and severe dyspnoea occurred. The greater portion of the growth was removed with tube-forceps, but a small fragment defied all attempts at evulsion (Fig. 30). Fig. 3°- Under these circumstances, the voice having become quite natural, and having remained so for three months, the patient did not care to persevere with treatment. Case XXV.—(Cystic) Tumour on the Epiglottis ; Treatment by Incision and Cauterization ; Cure. Maria G., aet. 24, was sent to me by Mr. Gayton, of Brick Lane, February 20th, 1866. She complained of considerable difficulty in swallowing during the last six months. Neither the breathing nor the voice was affected, nor was there any cough. She, however, experienced a sensation as of a lump in the throat, which obstructed the food on attempts at deglutition. The laryngoscope showed an ovoid tumour on the left side of the upper surface of the epiglottis. Fig. 31- On examination with the laryngeal sound, it was found to be soft, and diagnosed to be cystic. A few small vessels were seen ramifying on its surface (Fig. 31, and Plate II. fig. 6). The case 18 132 On Grozvths in the Larynx. was watched for some weeks; at the end of June, however, a free incision was made into the cyst, and a quantity of sebaceous-like matter evacuated. A probe coated with nitrate of silver was then introduced for a few seconds. A week later there was no vestige of the tumour, nor of the scar made in incising it.—Medical Times and Gazette, 1868, vol. i. p. 631. Case XXVI.—Papillary Growth on the Inter-arytenoid Fold; Treatment by Evulsion ; Cure. Charles B., aet. 35, vocalist, attended at the Hospital for Diseases of the Throat, March 19th, 1866, on account of slight hoarseness in speaking, and complete inability to sing. My attention was called to the case by Dr. Pratt, at that time acting as one of the clinical assistants of the Hospital, who discovered a growth on the fold between the arytenoid cartilages. The patient had attended nine months previously on account of congestion of the larynx, but at that period there were no signs of any growth, and after a short attendance he had resumed his vocation. On making a laryngoscopic examination, I was able completely to verify Dr. Pratt's diagnosis. There was seen to be a small column- like growth, about the size of a grain of wheat, protruding upwards and forwards from the inter-arytenoid commissure (Fig. 32). Fig. 32. The whole of the mucous membrane of the larynx was slightly congested. At the second visit, the growth was easily removed with the tube-forceps. On microscopical examination, it was found to consist of papillae covered with squamous epithelium, and of a small amount of con- nective tissue. A week later, there was a slight inflammatory thickening of the fold, but no appearance of the growth, and at the end of May the patient was able to accept an engagement at one of the music-halls. ioo Consecutive Cases treated by the Author. 133 Cask XXXII.—(Fibrous) Growth on the Right Vocal Cord; Treat- ment by Division of Base of Growth, and Subsequent Removal ; Cure. Mary R., aet. 57, wife of a stonemason, attended at the Hospital for Diseases of the Throat, March 3rd, 1866, on account of hoarse- ness, which had existed for three years ; occasionally during this period she had completely lost her voice for a day or two. On laryngoscopic examination, a small, smooth, ovoid growth, about the size of a horse-bean, was seen attached to the centre of the right vocal cord. The growth was situated at the free edge of the cord, and its long diameter was in the antero-posterior direction. The position and connection of the tumour seemed to render it a favourable case for division of the base of the growth. This opera- tion was accordingly performed by means of my laryngeal lancet, at the third visit of the patient, March 14th, in the presence of Dr. Tatham and Dr. Chisholm of Charleston, U. S. There was slight haemorrhage, and the condition of the larynx could not be clearly ascertained immediately afterwards; but on the following morning the growth was seen to be hanging by a mere shred. It was easily removed by tube-forceps. At the end of a month the voice was quite natural, and the larynx was seen to be perfectly healthy. Case XXVIII.—Fibrous Grozoth on the Right Ventricular Band; Treatment by Evulsion ; Cure. Mrs. H., aged 45, was sent to see me at the Hospital for Diseases of the Throat, by Mr. Hind, of Gravesend, April 12th, 1866, with the following history. For the last four years, she had had a frequent desire to swallow her saliva, and had often experienced great pain in the deglutition of food. During this time the voice had been slightly hoarse. In December, 1865, the breathing had become short, and during the winter she had several times suffered from alarming paroxysms of dyspnoea. Examination with the laryngoscope showed a large, mobile, pedunculated growth, seemingly attached to the right ventri- cular band. In inspiration, a portion of the right vocal cord could be seen (Fig. ^^), but in forced expiration, the growth was pushed upwards and across the larynx, so as not only to conceal the right, 134 On Growths in the Larynx. but in part also to cover the left vocal cord (Fig. 34). The whole of the tumour was removed in four sittings, with ordinary forceps. This Fig. 33- Fig. 34. case was examined by Dr. Pratt and other gentlemen, both before and after treatment. The larynx is now (June, 1868) perfectly normal, and the patient has since remained quite well. Dr. Andrew Clark kindly examined this growth, and pronounced it to be of simple fibrous structure.—Medical Times and Gazette, 1868, vol. i. page 631. Case XXIX.—Small Papillary Growth on each Vocal Cord; Treatment by Evulsion ; Cure. Mr. J. P. M., aet. 60, of Lancaster, was brought to me June 29th, 1866, by Mr. Paget. The patient stated that he had been suffering from gradually increasing hoarseness for three years, and that for the last eight months his voice had become entirely suppressed. His breathing was not at all impaired, nor had he any cough; but he had lately noticed a slighty increased desire to expectorate ; his swallowing was not painful, and his general health did not seem at all affected. He stated that four years previously he had suffered severely from pain in the head, the result, he thought, of over-work. He was now, however, gaining flesh, and had a good appetite. Examination with the laryngoscope showed a small round papil- liform growth on each vocal cord; the wart on the left cord was about a quarter of an inch from its anterior insertion, and that on the right cord was situated on its cartilaginous portion (Fig. 35). IOO Consecutive Cases treated by the Author. 135 The small size of the growths rendered operative procedures very difficult, and it took forty sittings to remove the whole of them. Tube-forceps were employed in this case. I have frequently seen this patient since. He has had no recurrence of the growth, but occasion- ally suffers from congestion of the larynx. He speaks now in his natural voice.—Medical Times and Gazette, 1868, vol. i. page 632. Case XXX.—(Papillary) Grozvths on both Ventricular Bands; Treatment by Evulsion ; Cure. W. S., aet. 49, stableman, applied at the Hospital for Diseases of the Throat in July, 1866, complaining of hoarseness, unaccom- panied by any other symptom. My attention was called to the case by my colleague, Mr. Evans, who first saw the patient, and transferred him to me. On laryngoscopic examination, small pink fimbriated growths were seen projecting from both ventricular bands (Fig. 36). The Fig. 36. growth on the right side was removed at the first sitting; that on the left band, after a few unsuccessful and partially successful attempts, on September 10th. The patient entirely regained his voice, and a fortnight after the last operation there was not the least abnormal appearance in the larynx. Case XXXI.—Pedunculated (Papillary) Grozvth on the Left Vocal Cord; Treatment by Incision of the Base of the Grozvth ; Cure. J. N., aet. 23, a street singer, was first seen at the Hospital for Diseases of the Throat in November, 1866. The prominent symptoms, in this case, were dysphonia and a frequent hacking cough, unaccompanied by expectoration. With the aid of the laryngoscope, a small warty growth was seen to be attached by a distinct pedicle to the centre of the left vocal cord. 136 On Grozvths in the Larynx. In the presence of Drs. Taylor, Merryweather, and other gentle- men, the growth was incised with my laryngeal lancet. A week later the growth was not a third of its previous size, and had a grey sloughy appearance. On January 30th, 1867, the larynx was per- fectly free from any sign of the growth, though there was still slight congestion. About six months later, that is, on July 18th, 1867, this patient applied again, on account of an attack of quinsey. On recovery from the tonsillitis, his larynx was examined, and there was not the least appearance of the growth : he stated that " he had been able to pursue his profession as an Ethiopian Serenader with- out the least discomfort" since he left the hospital. Case XXXII.—Small (Papillary) Grozvth on the Left Capitulum Santorini; Treatment by Evulsion ; Cure. Catherine H., aet. 50, laundress, applied as an out-door patient at the Hospital for Diseases of the Throat in the latter part of December, 1866, on account of shortness of breath, which was very much increased on exertion. The patient spoke in a husky voice; but she said that her voice had been so long rather gruff that she scarcely noticed it, and that it was of no con seem ence to her. She had frequently suffered from sore throat, but the dyspnoea had only come on during the last five months. On laryngoscopic examination, a small pedunculated growth was seen to be attached to the mucous membrane over the capitulum Santorini (Fig. 37). Fig. 37- This was easily seized and removed with tube-forceps at the second visit, in the presence of Mr. Evans. The patient did not apply again till ist February, 1867, when all symptoms had passed away, and with them all trace of the growth. ioo Consecutive Cases treated by the Author. 137 Case XX XI11.—Small (Papillary) Grozvth on the Left Vocal Cord; Treatment by Evulsion ; Cure. Mr. S. C, aet. 37, a vocalist, consulted me in December, 1866, on account of hoarseness, which had prevented him taking any engagement for the last two years. He had spent two months of the previons summer at Ems, and had come to me from Torquay, where he had been recommended to pass the winter, in the belief that he was suffering from laryngeal phthisis. The patient was • exceedingly nervous and dispirited, and had lost flesh. An addi- tional cause of anxiety existed in the fact that an elder brother, not long previously, had died from disease of the lungs. On laryngoscopic examination, a well-defined growth, about the size of a barleycorn, was seen just in front of the vocal process of the left vocal cord (Fig. 38), preventing proper approximation in attempted phonation. A careful stethoscopic examination showed no signs of chest disease; and the patient stated that an opinion to this effect had been given by several physicians, though no explanation had hitherto been afforded as to the nature of his disease. I had the opportunity of showing this case to my col- league, Mr. George Evans, who examined the patient both before and after treatment. Great difficulty was experienced in operating in this case, on account of the patient's nervousness ; and it was only after Mr. C. had sucked ice for a quarter of an hour before each examination, that the irritability was sufficiently relieved to enable me to introduce any instrument. Very many unsuccessful attempts, with every variety of forceps, were made before the growth was removed. Never- theless, on March 10th, 1867, I succeeded in removing it with tube-forceps. I have frequently seen this gentleman since. He has quite recovered his voice, and is able to take engagements, and to teach singing to a large number of pupils, without the slightest discomfort or disability. 138 On Growths in the Larynx. Case XXXIV.—(Papillary) Grozvth on the Left Vocal Cord; Treatment by Evulsion; Cure. Mrs. C E., aet. 46, was sent to me by the late Dr. Brmton, December 14th, 1866, on account of loss of voice, which she had experienced for six years, with gradually increasing hoarseness for five years previously. In 1862 she had been examined by Professor Czermak, but the patient did not know what his opinion had been. On examination with the laryngoscope, a small pedunculated growth, about the size of a pea, was seen attached to the anterior extremity of the left vocal cord (Fig. 39). On the third attempt, the Fig. 39- whole of the growth was removed with tube-forceps. In May, 1867, the patient's voice was perfectly natural, and the larynx looked quite healthy. I had the opportunity of showing this case, both before and after treatment, to two experienced laryngoscopists, Dr. Hun, of Albany, and Dr. Lockwood, of New York.—Medical Times and Gazette, 1868, vol. i. page 632. Case XXXV.—Large (Papillomatous) Growth on the Right Vocal Cord; Treatment by Evulsion ; Cure. Henry Y., aet. 40, railway porter, from Surbiton, applied at the Hospital for Diseases of the Throat in the early part of January, 1867, on account of hoarseness. He stated that he first observed his voice to fail in September, 1865. One of his duties was to call out the names of the station on arrival of trains. His hoarseness increased so much that in March, 1866, he was relieved from that portion of his duty. The voice, however, instead of improving, gradually became worse. The patient complained of no other symptom but the hoarseness. On laryngoscopic examination, a growth, about as large as a Barcelona nut, was at once seen springing from the middle of the IOO Consecutive Cases treated by the Author. 139 right vocal cord (Fig. 40). The mucous membrane of the larynx was generally congested. The growth, being in a favourable position, Fig. 40. was easily removed in a few visits by tube and common antero- posterior forceps. During the progress of treatment this patient was seen by Dr. Pogojeff, of Odessa, Mr. Du Pasquier, and several other gentlemen at that time attending the practice of the hospital. Case XXXVI.—(Fibrous) Growths on the Right Vocal Cord; Excision of small Pieces : no Lmprovement; Tracheotomy. J. K., aet. 54, a gardener, was admitted as an out-patient at the Hospital for Diseases of the Throat, January 17th, 1867, on account of loss of voice and difficulty of breathing. He stated that three years previously he had caught a severe cold, which had affected his throat and chest. Since then he had never quite recovered his voice, and for the last twelve months it had become entirely suppressed. For the past eight months he had suffered from shortness of breath, on the least exertion, so that he had been quite unable to follow his occupation, and latterly he had been several times awakened from his sleep by alarming attacks of suffocation. On examination with the laryngoscope, the whole of the windpipe was seen to be inflamed and swollen; along the right vocal cord were several round nodulated growths, intimately associated with the structure of the cord. After some weeks of local treatment, in the form of inhalations and topical application of mineral astrin- gents, the inflammation was very much reduced, and attempts at evulsion of the growth were made. The neoplasms were, however, so dense in structure, and so firmly adherent, that the use of forceps proved quite unavailing. Several small pieces were divided with the laryngeal lancet; but this did not give much relief, and the dyspnoea and attacks of strangulation increasing, the patient was 19 140 On Growths hi the Larynx. admitted into the wards in April. He was unwilling to submit to any further treatment for the removal of the growths; so on April 7th, Mr. Evans performed tracheotomy, and he left the hospital, wearing his tube, at the end of three weeks. This patient presented himself at the- hospital in June, 1868, desiring that the canula might be removed ; but as the larynx presented a similar appearance to that seen before the operation, this step was not recommended. Case XXXVII.—Papillomatous Growth on the Right Vocal Cord ; a smaller one on Under Surface of Epiglottis; Partial Evulsion ; Lmprovement of Voice; Return of Symptoms ; Similar Treatment, and Complete Recovery. Mr. W. H. H., aet. 40, an overseer of mines, was brought to me in February, 1867, by an able laryngoscopist, Dr. Griffiths, of Swansea. The only symptom was complete suppression of voice. For the last three years he had been quite unable to sound his voice, but previously to that time he had been hoarse. Examination with the laryngoscope discovered a large highly- divided growth, occupying half of the right vocal cord, and a small smooth wart on the left side of the under surface of the epiglottis (Fig. 41). The latter was immediately removed with the tube- Fig. 41. forceps, and the greater part of the growth on the right vocal cord, with the same instrument at a subsequent visit. The voice im- proved greatly immediately after this operation, and the patient left town a few days later, satisfied with the great improvement that had taken place, but with a very small portion of the growth still attached to the anterior part of the right vocal cord. May 25th, 1868.—Mr. W. H. H. called on me with a larger growth on the epiglottis than the one I had previously removed, and a recurrence of the excrescence on the vocal cord. These growths were again removed with tube-forceps, and the patient left town in 100 Consecutive Cases treated by the Author. 141 a week with a good voice. A portion of this growth was examined by Dr. Fenwick, who reported that it was of warty character. In a note received from Dr. Griffiths, December 15th, 1870, he states : " I found Mr. W. H. H. at last. His general health is excellent, and he tells me that his voice is ' capital.' " Case XXXVIII.—Fringe-like (Papillary) Grozvth on the Posterior Wall of the Larynx ; Partial Destruction by Galvanic Cautery ; Negative Result. Mrs. W., aet. 56, was recommended to consult me in March, 1867, by Dr. Addington Symonds, of Clifton, on account of chronic dysphonia. She complained also of cough, and a tendency to sickness. The symptoms had commenced with a slight attack of laryngitis, accompanied with some dyspnoea; but though, on recovery from the attack, the breathing had become natural, her voice continued hoarse. On laryngoscopic examination, a pale fringe-like growth was seen projecting from the posterior wall of the larynx, and extending from the level of one cartilage of Wrisberg to the other (Fig. 42, and Fig. 42- Plate II. fig. 5). From the easy situation and comparative flatness of the growth, it seemed a most favourable case for electric cautery. The pointed laryngeal instrument, with a four-celled Smee's battery, was used. Two days later, it was found that about a third of the growth on the right side was destroyed, and that in its place there was a greyish slough; the patient, however, complained of having experienced such severe pain in the ears after the first cauterization, that she would not consent to any further treatment of a similar kind. I saw her several times afterwards, but there was still thickening of the posterior wall of the larynx, and she did not appear to have derived much benefit from the treatment. 142 On Growths in the Larynx. Case XXXIX.—Small Fibroma on the Anterior Portion of the Left Vocal Cord; Slight Alteration in Voice; Treatment by Evul- sion ; Cure. Mr. T., aet. 27, a vocalist and comedian, from New York, was recommended through Dr. Marion Sims to consult me on his arrival in England. He called on me March 15th, 1867, and stated that his singing voice had been entirely lost for two years, though pre- viously he was considered a powerful tenor. His ordinary speaking voice was not apparently affected, though he fancied it had changed tone, and frequently it required a considerable effort on his part to make himself heard on the stage. On laryngoscopic examination, a small, smooth, bright red, poly- ' poid, growth was seen on the upper surface of the left vocal cord, close to the anterior commissure (Fig. 43). The neoplasm did not project beyond the free edge of the vocal cord, but appeared to rotate slightly from above downwards. The vocal cords themselves were quite normal. The movement of the growth led to the sup- position that it had a narrow peduncle attached either to the vocal cord or to the lower edge of the ventricle. At the second visit, the growth was seized with the tube-forceps, and easily removed. Ex- amined microscopically, the growth was found to consist entirely of white fibrous tissue. I saw Mr. T. six months later, and he had then quite regained his singing voice, though he had lost some of his higher notes. Case XL.—Symmetrical (Papillomatous) Grozvths on both Vocal Cords ; almost Complete Evulsion ; Great Lmprovement. Henry S., a labourer, aet. 32, applied at the Hospital for Diseases of the Throat, March 21st, 1867, on account of complete loss of voice. He had been hoarse for nine years, and for two years and a IOO Consecutive Cases treated by the Author. 143 half the voice had been altogether suppressed. His breathing was not at all impaired. The laryngoscope revealed a cauliflower-looking growth on each vocal cord. The neoplasms, which were symmetrical, were situated at the junction of the anterior third with the posterior two-thirds of the cords (Fig. 44). The patient denied ever having had syphilis. t'ig- 4-1- On the first visit, the whole of the growth on the right vocal cord was removed with the common antero-posterior forceps, in the presence of Dr. Padley, of Swansea. On the next visit, March 28th, there was no perceptible improvement in the voice. On examining the larynx, the mucous membrane was seen to be in a state of extreme congestion ; and it was deemed advisable to defer any operation on the remaining growth. It was not till April 25th that I was able to introduce an instrument within the larynx, when, in the presence of Dr. M'Call Anderson, I removed what appeared to be the whole of the growth on the left cord. Three days later, how- ever, a very small portion was still seen to remain. The patient did not attend again for three weeks, when he presented himself as cured. The voice, though strong and phonetic, was not quite clear, and I could see that in phonation the cords did not accurately approximate, on account of the small piece (not larger than a pin's head) of the growth that remained on the left side. The patient, however, was so satisfied with his condition, that he declined to have any further treatment. Case XLI.—Fibro-cellular Polypus on Under Surface of the Epi- glottis ; Treatment by Galvanic Cautery; Cure. ■ Harriett T., aet. 28, servant, applied at the Hospital for Diseases of the Throat in the latter part of March, 1867, on account of hoarseness, which had been coming on since May, 1865, and had been attributed by her medical attendant to bronchitis. 144 On Grozvths in the Larynx. On laryngoscopic examination, the cause of the dysphonia was at once apparent, for a pale, semi-transparent pedunculated tumour was seen growing from the right side of the under surface of the epiglottis, near to its free edge (Fig. 45). Fig. 45- As at that time I was making experiments with the galvanic cautery, I determined to employ this agent. Before operating, I demonstrated the case for several successive Thursdays to the various medical practitioners at that time attend- ing the Hospital. The patient was seen by, amongst others, Dr. Atkinson and Dr. Maccaldin. On May 14th I passed an electric- cautery wire, connected with a Middeldorpf battery, round the growth, and on application of the current, it at once dropped off, and was expelled into the pharynx. On examination after removal, the growth was seen to be perfectly white, and contained a gelatinous substance like that found in nasal polypi. Four hours after the operation, the patient applied to me, on account of slight pain and difficulty in swallowing. On making a laryngoscopic examination, the orifice of the larynx was seen to be rather congested, and the edge of the epiglottis slightly cedematous. By sucking and swallowing ice for a few hours, the symptoms were relieved, and two days afterwards, the operation was found to have been perfectly successful. A month later, even the situation of the growth could not be discovered. Case XLII.—(Fibroma) on Superior Surface of the Right Vocal Cord; Unsuccessful Attempts at Evulsion; Treatment by Galvanic Cautery ; Subsequent Laryngitis ; Ultimate Cure. The Rev. C. F. D., a missionary, who had been many years in the Bombay Presidency, but had been obliged to suspend his labours during the last two years, on account of gradually failing voice, applied to me, May 5th,- 1867. He had been recommended to try 100 Consecutive Cases treated by the Author. 145 change of climate to Europe, and had had his uvula removed. No laryngoscopic examination had, however, been made up to the time he came to me. On using the mirror, a smooth and but slightly elevated growth was seen covering the middle third of the right vocal cord. In vocalization it impinged against the left cord, so that neither could completely advance to the median line (Fig. 46, and Plate II. fig. 4). Fig. 46. Several unsuccessful attempts at removal having been made with a great variety of growth-forceps, it was determined to employ the galvanic cautery. This was accordingly done on July 14th. My assistant, Mr. Lennox Browne, attended to the battery, whilst I employed the pointed electrode. The same evening the patient suffered from great dyspnoea, and had symptoms of acute laryngitis : the whole of the mucous membrane of the larynx was seen to be greatly inflamed, and the right ventricular band was oedematous. I was anxious to scarify the part, but the patient would not consent to it. He was directed to use warm inhalations of compound tincture of benzoin, and the next morning I found him considerably relieved. There was still so much congestion of the larynx, that the condition of the right vocal cord could not be seen. On the 16th a black eschar was observed to occupy the greater part of the vocal cord which had been touched. A week later, the cord had a uniform grey appearance. The patient was not seen again till the 20th of September, and at that time, with the exception of slight redness of the right vocal cord, the whole of the larynx was perfectly healthy. Case XLIII.—Papillary Growth on the Posterior Wall of the Larynx ; Treatment by Evulsion ; Cure. Eliza C, aet. 53, married, applied at the Hospital for Diseases of the Throat, May 10th, 1867, on account of shortness of breath and 146 On Grozvths in the Larynx. loss of voice. She stated that she had frequently suffered from quinsey, but that difficulty of breathing had first come on eighteen months previously. Her voice first became hoarse a year ago, and had only been altogether suppressed during the last seven months. She also complained of a frequent cough, which was apparently caused by an itching sensation in the throat. There was no evidence of the existence of either phthisis or syphilis. On laryngoscopic examination, the larynx was naturally very small, and the posterior half of the glottis was seen to be occupied by a white cauliflower excrescence growing from the posterior wall of the larynx (Fig. 47). The lungs were examined, and appeared to be healthy. Fig. 47- The case being urgent, treatment was at once adopted, and a large fragment was removed at the first visit with tube-forceps, in the presence of Dr. Longmarsh and Staff Assistant-Surgeon Semple. A week later, the breathing was found to be much improved, and only a small portion of the growth remained. This was easily removed with the same instrument. The growth was examined microscopically by Dr. Andrew Clark, and pronounced to be "a simple papillary formation." Case XLIV.—Papillary Grozvth on the Right Ventricular Band; Treatment by Evulsion ; Cure. Sarah F., aet. 41, a married woman, came under my care at the London Hospital, in June, 1867, on account of hoarseness of six years' standing. The voice was not completely lost, but the patient spoke very gruffly. She also complained of occasional attacks of dyspnoea, and stated that she had twice lately awoke early in the night with a feeling of suffocation. She had a slight tickling cough, unaccompanied with expectoration. On laryngoscopic examina- tion, a cauliflower-like growth, about the size of a bean, was seen on the right ventricular band. On inspiration the growth covered 100 Consecutive Cases treated by the Author. 147 the posterior four-fifths of the right vocal cord (Fig. 48), but on attempted vocalization it projected across the glottis, and covered the middle third of the left vocal cord (Fig. 49). Two unsuccessful Fig. 48. Fig. 49. attempts were made to seize the growth in July, but in the following September the whole of it was removed with tube-forceps. The tumour was examined microscopically by Dr. Andrew Clark, and pronounced to be a simple papilloma. Case XLV.—Large Papillomatous Growths on both Vocal Cords; Evulsion of a Portion ; Discontinuance of Treatment on account of Pregnancy of Patient ; Subsequent Tracheotomy. Mrs. J. M. B., aet. 30, a watchmaker's wife, from Clapton, was admitted into the Hospital for Diseases of the Throat, June 13th, 1867, on account of great dyspnoea, accompanied with aphonia. The aphonia had existed three years, but the dyspnoea only a few weeks. The patient was pregnant. On laryngoscopic examination, both vocal cords .were seen to be covered with large cauliflower excrescences. The mass on the right vocal cord grew upwards and completely occupied the right half of the cavity of the larynx (Fig. 50). I removed several large pieces with tube-forceps, but the patient was obliged to leave the hospital in the early part of September, her general condition at the time rendering further treatment difficult. On the 24th of November her respiration was so seriously embarrassed, that Mr. De Berdt Hovell, of Clapton, 20 148 On Grozvths in the Larynx. performed tracheotomy. She recovered well, and was delivered of a still-born child, January 4th, 1868. Mr. Hovell kindly communicated to me (April 5th, 1870) the following notes of her condition :— " Her present condition is pretty well. The tube is still in ; she has recovered her voice, although not its full power; she has been confined, as you know, of a dead child since the operation, and is expecting her.confinement again next month." Case XLVI.—Numerous (Papillomatous) Growths in the Larynx; Treatment by Evulsion; Recovery of Voice; Subsequent Recur- rence j Cure. Miss M., aet. 30, the sister of a physician, consulted me, May 2nd, 1867, on account of loss of voice and shortness of breath. She stated that eleven years ago she first became hoarse. Previous to that time she had a soprano voice, and was accustomed to sing a good deal. She thus described the development of the hoarseness :—- " My voice altered, first losing high notes, then becoming a whisper, and wavering from time to time at every change of weather and climate." For the last two years she had occasionally noticed that her respiration was embarrassed, and she complained of a frequent desire to clear the throat. On making a laryngoscopic examination, the whole of the interior of the larynx, with the exception of the epiglottis, was seen to be covered with small warty excrescences, and one small'growth was seen to be attached beneath the anterior commissure of the vocal cords (Fig. 51). Owing to the small size of the larynx, the treatment was carried out with some difficulty, with the aid of tube-forceps, and it required two months, with almost daily sittings, to clear the larynx. The patient left town with a good voice, and with perfectly easy respiration. This lady called on me, June 27th, 1870, and I found there was 100 Consecutive Cases treated by the Author. 149 a recurrence of the growth on the ventricular band and vocal cord, on the right side. Her voice was phonetic, but rather shrill. Treatment was again pursued with tube-forceps, and early in March, 1871, the larynx was again completely cleared. Case XLVIL—(Papillary) Growths on the Vocal Cords; Treatment by Evulsion; Cure. John T., aet. 45, a shoemaker, applied at the Hospital for Diseases of the Throat, July 9th, 1867, on account of a bad cough, accom- panied by hoarseness. He stated that for some years he had suffered from an irritable cough, with a desire to clear the throat of some obstruction that seemed to be constantly present. For the last eighteen months the cough had increased in frequency and severity, and the attacks sometimes lasted for many minutes. The cough was always excited when he lay down, or if he attempted to stoop over his work. The hoarseness had only commenced about a year and a half previously; it had gradually increased, until, at the time of application at the Hospital, his voice was entirely sup- pressed. On laryngoscopic examination, a large warty growth was seen projecting from the middle third of the right vocal cord, and on the left side there was another irregular neoplasm growing from the edge of the cord. The cords were generally jagged and irregular in out- line, and the mucous membrane of both pharynx and larynx was much congested and relaxed. It was not till after some weeks of local treatment by mineral astringents that the congestion of the larynx was sufficiently reduced to admit of attempts at removal of the growth. The tumour on the right side was eradicated with the common antero-posterior forceps at the first attempt; but the growth on the left side required sixteen sittings, at which both the common and tube-forceps were used, before it could be entirely removed. After evulsion of the larger portions, the cough quite ceased, but it was not till the larynx had been quite clear for some months that the voice was completely restored. This case was seen during treatment by Surgeon-Major Trestrail and the Rev. David Bell, M.D., of Goole, as well as by many other practitioners. 15° On Grozvths in the Larynx. Case XLVIII.—Fibro-cellular Growth on the Under Surface of Epiglottis; Treatment by Evulsion ; Cure. Joseph L., aet. 30, a furniture-dealer, applied at the Hospital for Diseases of the Throat, July 18th, 1867, on account of loss of voice, of nine months' duration. He served in an open shop, and was a good deal exposed to cold and draughts. On making a laryngo- scopic examination, a small, red, irregular, pedunculated, growth was seen attached to the under surface of the epiglottis, close to the commissure of the vocal cords (Fig. 52). On the second visit Fig. 52. (July 2ist), in the presence of Surgeon-Major Trestrail, I removed the whole of the growth with tube-forceps. A week later (July 28th) the voice was entirely restored, and there was no appearance of the growth. On microscopic examination, this growth was found to consist of fibro-cellular tissue, in which, on the addition of acetic acid, numerous nuclei were apparent. There was a small amount of interstitial fluid, and in it were a few nucleated cells. Case XLIX.—Fasciculated Sarcoma on the Under Surface of the Epiglottis; Treatment by Galvano-cautery and Evulsion ; Great Improvement; Recurrence. Anne H., aet. 53, unmarried, a Bible-reader, first came under my notice 111 July, 1869, complaining of loss of voice and extreme dyspnoea. She experienced great pain in attempting to speak, and there was also so much pain in swallowing, that for some time she had only been able to take food of fluid, or semi-fluid consistence. On laryngoscopic examination, a smooth, red, neoplasm, about the size of a kidney-bean, was seen on the under surface of the epiglottis (Fig. 53, and Plate III. fig. 3). The position of the growth was very similar to that in the last case; but in this instance it was much larger and had a broad base.. On making 100 Consecutive Cases treated by the Author. 151 an examination with the laryngeal sound, the polypus was found to be unusually hard. Several attempts were made to remove it with forceps, but, owing to the gristle-like consistence of the Fig. S3- tumour, they only resulted in the tearing away of small portions of superficial mucous membrane. It was therefore determined to use the electric cautery. The first application was made on January 16th, 1868, with the aid of my assistant, Mr. Lennox Browne. The patient experienced but little inconvenience from this treatment, and, ten days afterwards, the growth seemed to be sensibly diminished in size. A second application was made March 5th, and though some pain was felt after the operation, it appeared to have a decidedly beneficial effect on the size of the growth. In the summer of 1868 the treatment had been so successful, that the patient was able to take ordinary food, and her voice was almost restored to a natural tone, so that she was able to resume her occupation in the London Female Bible Mission. This entails not only a good deal of talking and reading, but also exposure to all kinds of atmosphere and temperature. In January, 1870, a recur- rence of the growth having taken place in the same situation, I removed a piece with my cutting forceps ; it was exceedingly hard and difficult to tear away. On microscopic examination by my brother, Mr. Stephen Mackenzie, it was seen to consist, in parts, of simple fibrous tissue; but in others, abundance of nuclei were found, amongst long interlacing fibres (Plate I. fig. 7). This growth resembled the fibro-nucleated tumour of Dr. Hughes Bennett. There is still a slight projection from the under surface of the epiglottis, but it is scarcely sufficiently defined to warrant any further interference. 152 On Grozvths in the Larynx. Case I,.—(Papillary) Growth on the Right Vocal Cord; Treatment by Evulsion ; Cure. Mr. S., aet. 64, a merchant, was recommended to consult me by Mr. Ince, September 10th, 1867, on account of aphonia, of three years' standing. He had, however, been hoarse, to a slight extent, for four years, and during that time had tried a great variety of medical and climatic treatment. He attributed his affection to a severe cold, which he had caught whilst travelling by railway at night. On laryngoscopic examination, a small mammillated growth of dark red colour was seen springing from the right vocal cord, at about its middle third. The greater portion was removed on the first attempt, but a small fragment, scarcely larger than a pin's head, remained. The voice did not at all improve until January, 1868, when, after a number of unsuccessful attempts, I succeeded in removing the remaining portion, my assistant, Mr. Lennox Browne, being present at the operation. Case LI.—(Papillary) Growth on the Right Vocal Cord; Evulsion and Crushing; Cure. W. W., aet. 55, a druggist's dispenser, from Greenwich, applied at the Hospital for Diseases of the Throat, in October, 1867, on account of complete loss of voice, which had come on quite suddenly three years before. For the last ten years he had occa- sionally lost his voice for a day or two, but had always recovered it. He had also lately, on two occasions, awoke suddenly in the night with a sensation of suffocation. He had suffered from con- stitutional syphilis, from time to time, since he was twenty-six years old. On laryngoscopic examination, a smooth white growth, the size of a haricot bean, was seen attached to the right vocal cord, which was considerably congested. The vocal cords remained widely apart on attempted phonation. A considerable fragment was removed with common antero- posterior forceps, in the presence of Surgeon-Major Trestrail and other practitioners, on October 24th, but the remaining portion 100 Consecutive Cases treated by the Author. 153 was of so dense a structure, and so firmly adherent, that it could not be removed, except with more force than was considered justi- fiable. After repeated crushings, however, the growth gradually atrophied, and at Christmas there remained only a slight uneven- ness of the right vocal cord. The cords approximated well, but were slightly congested ; the voice was fairly good. Case LII.—Fibro-cellular Grozvth on the Right Vocal Cord; Treat- ment by Evulsion; Complete Removal at first Operation; Cure. Mrs. R., aet. 65, consulted me on the 8th of October, 1867, on account of loss of voice and difficulty of breathing, which had been coming on since the year 1852. For the last seven years she had been very hoarse, but during the last twelve months her voice had been entirely suppressed. On making a laryngoscopic examination, a large, red, globular growth was seen occupying the anterior three-fourths of the glottis (Fig. 54, and Plate II. fig. 10). It was very mobile, and therefore judged to be pedunculated ; but as its base was entirely hidden, its origin could not "be ascertained. On the 30th of October, the entire growth was removed with the common laryngeal forceps. Immediately after its removal, the patient spoke in a clear natural voice, but she became a little hoarse the same evening. The next day it was seen that the growth had been attached to the posterior part of the right vocal cord. A slight roughness and hyperaemia in this situation indicated its previous base. Ten days later, the larynx was seen to be perfectly healthy, and the voice and breathing natural. The growth (Plate II. fig. 10) was at that time the largest I had removed through the mouth, without previously per- forming tracheotomy. It measured, on removal, more than six-eighths of an inch in its long diameter, and one inch and 154 On Growths in the Larynx. three-eighths in circumference. Pathologically it was considered a fibro-mucous polypus.—Transactions of the Pathological Society, vol. xxi., January 21st, 1868. Case LIII.—(Papillary) Growths along the whole extent of both Vocal Cords; Partial Evulsion; Lmprovement. W. H., aet. 26, a journeyman butcher, applied at the Hospital for Diseases of the Throat, November 6th, 1867. Five years previously he had contracted syphilis, and ten weeks after the primary affection, had had sore throat and a copper-coloured eruption on the skin. Two years ago he had a bad ulcerated sore throat, and his voice became very hoarse. Nevertheless he had continued his occupation (which involved the constant use of his voice outside a shop in the evening) until two months previous to his coming to the Hospital. On laryngoscopic examination, the mucous membrane of the larynx was seen to be in a state of extreme hyperaemia, and both vocal cords were covered with small irregular growths, of a bright- red colour (Fig. 55). Owing to the patient being very nervous, Fig. 55- and unable to remain still, several unsuccessful attempts were made before any portion could be removed, and he was consequently very much discouraged. It was not till February 6th that two or three small pieces were removed from the right vocal cord, in the presence of Surgeon-Major Trestrail. On the 13th another piece was removed. On the 20th his voice was found to be somewhat improved. The right vocal cord was then quite clear, but the posterior half of the left vocal cord was still covered by an irregular excrescence. The patient did not attend again. ioo Consecutive Cases treated by'the Author. 155 Case IAN .—(Benign Epithelial) Growth on the Right Vocal Cord; Treatment by Caustic and Astringent Solutions ; Cure. James B., aet. 43, a small farmer, applied at the Hospital for Diseases of the Throat, December 12th, 1867, on account of hoarse- ness, which had existed for fourteen months. On making a laryn- goscopic examination, a pale and very smooth growth, about the size of a split tare, was seen projecting from the free edge of the right vocal cord, at its posterior third. The patient was kept under observation for two months, without any treatment, in order that the progress of the case might be watched ; but the tumour did not undergo any change. Strong solutions of nitrate of silver, iron- alum, and persulphate of iron, were then carefully applied to the tumour about twice a week for six months. At the end of this time the tumour had gradually disappeared, and the voice, which had been slowly improving, had become quite clear. I may mention that in this case the small swelling remained visible, when the vocal cords were in a state of tension, for several weeks after it had ceased to be seen when the cords were relaxed. This case being a rather remarkable one, was repeatedly brought under the notice of the medical practitioners who, during the patient's course of treatment, were attending the hospital. It was especially known to Surgeon- Major Trestrail and Mr. Lennox Browne. Case IN .—Pedunculated (Papillary) Growth on the Left Vocal Cord; Treatment by Evulsion ; Cure. W. K., aet. 13, a washerwoman's son, applied at the Hospital for Diseases of the Throat, December 16th, 1867, on account of shortness of breath and hoarseness. The mother stated that her boy had an attack of croup when three years old, and since that time he had frequently suffered from sore throat. In 1865 she had brought him to this hospital, and at that time he had been treated for inflammation of the windpipe. Six months previous to his present application he had had scarlet fever, which was followed by enlargement of the glands of the neck. She stated further, that, occasionally, he had a croupy cough at night, and that his breathing was often embarrassed. The boy complained of a feeling of dryness, and, at times, of a sensation of choking. The voice was gruff, and, at intervals, altogether suppressed. On larvn- 21 156 On Grozvths in the Larynx. goscopic examination, a wart-like growth about the size of a pea was discovered projecting from the middle of the left vocal cord. No attempt at removal was made at the first visit of the patient, but a week later, the growth was easily seized with tube-forceps, and the whole of it removed, in the presence of Drs. Welch and Pelechin. He was seen at the end of March ; the larynx was clear, his voice normal, and he was perfectly well in every respect. Case LVI.—Fibroma on Under Surface of Epiglottis; Treatment by Evulsion j Cure. Henry W., aet. 34, a sugar-baker, applied at the London Hospital in December, 1867, on account of difficulty of swallowing and a constant disposition to clear his throat. These symptoms had been coming on for two years and a half, but had become much worse during the last ten months. A laryngoscopic examination showed a smooth, pale red, growth on the left side of the larynx. The origin of the neoplasm, which was about the size of a haricot bean, could not be made out ; but it was believed, at the time, to be attached to the epiglottis. On the 4th of December the entire growth was removed with common laryngeal forceps. The case was seen before and after treatment by Dr. Alexander Fox. Examined microscopically, the growth was found to be of an obscurely fibrous structure. Case LVII.—(Papillary) Growth on the Left Vocal Cord and o?i Epiglottis ; Treatment by Evulsion and Crushing; Cure. W. W. R., aet. 17, an engine-fitter, from Barnstaple, was sent to me by Dr. Johnston, of that town, in December, 1867, on account of loss of voice, which had existed for two years. The boy was a skilled player on the cornet. He complained of dryness, and a sense of obstruction in the throat; he had a slight cough, and his voice was completely lost. There was no dyspnoea. On laryngoscopic examination, a small, bright red, growth, the size of a tare, was seen on the under surface of the epiglottis, on the right side; and an irregular warty growth, of pink colour, extended nearly the whole length of the left vocal cord (Plate II. fig- 7)- This growth was very moveable ; in inspiration, it was drawn down, and only occupying half the area of the glottis, looked about the size of a large bean (Plate II. fig. 7) ; but in forced IOO Consecutive Cases treated by the Author. 157 expiration, the growth occupied nearly the whole of the opening of the glottis, leaving only two minute chinks, one at the anterior and right side, and another at the posterior part of the larynx (Plate II. fig. 8). The boy was admitted into the Hospital for Diseases of the Throat, and remained there nearly four months, during which time a great number of operations were performed. The small polyp on the under surface of the epiglottis was at once eradicated. The larger growth, however, had a long and membranous base, and yielded to the slightest touch with an instrument, so that, when an attempt at evulsion was made, it rotated completely beneath the vocal cord, and left nothing but its thin membranous attachment visible (Plate II. fig. 9). This constituted a great difficulty, and accounts for the long time the boy remained under treatment. Ulti- mately, however, the growth was entirely removed, and he left the Hospital with his voice completely restored. Tube-forceps, common forceps, and Stoerk's e'craseur were used in this case. Shortly after the boy returned home, I was pleased to receive a letter from Dr. Johnston, acknowledging the satisfactory issue of this very difficult case. I saw this patient again in March, 1869. There was no return of the growth ; the larynx was normal in every respect, and the voice perfectly natural.—(Medical Times and Gazette, vol. i. 1868, page 632.) Case LVIII.—Benign Epithelial Grozvth on the Right Ventricular Band ; Treatment by Evulsion ; Cure. F. S., aet. 10, an artisan's child, was brought to me at the Hospital for Diseases of the Throat, by his father, on January 7th, 1868, on account of loss of voice and shortness of breath, which had existed since the child was six months old. At that age he had an attack of what was pronounced to be croup. Since then he had suffered from occasional severe attacks of suffocation at night, and once the father had been advised to take him to Middlesex Hospital, in order that the windpipe might be opened. The child remained in that institution a few days, but the symptoms subsided, and no operation was recommended. A laryngoscopic examination was easily made, and a red, fim- briated, neoplasm, about the size of a kidney-bean, was seen on the right ventricular band, near the edge of the ventricle. Several 158 On _ Grozvths in the Larynx. minute pieces were removed at various times, but it was not till February 13th that the last remaining portion was removed with the tube-forceps, in the presence of Dr. Alexander Hewan, Mr. Pugin Thornton, and others. On microscopic examination, the growth was found to consist entirely of epithelial cells in various stages of development. No connective tissue, nor papillae, could be discovered in the tumour. On March ist, the voice was completely restored, and there was no trace of the growth. Case LIX.—Fasciculated Sarcoma on the Right Vocal Cord and in the Right Ventricle; Treatment by Evulsion ; Constant Recurrence. R. P., aet. 42, a carman, was sent to me at the Hospital for Diseases of the Throat, January 13th, 1868, by Dr. Woolley, of Kentish Town, on account of loss of voice. On laryngoscopic examination, a white nodule, the size of a pea, was seen growing on the right vocal cord, at about its middle. The origin of the growth was merged in the substance of the vocal cord, there being no peduncle, line of demarcation, nor difference in colour. There was also a hard white nodule in the submucous tissue of the tongue, at about its centre. There was an obscurely syphilitic history; and on this account, and also because the growth was unfavourable for removal, the patient was treated for some time by the internal administration of iodide of potassium. The little tumour, however, underwent no improvement. In September, after a few weeks' absence, I saw that the growth had considerably increased in size, and that it had become irregularly lobulated. Several small particles were at different times removed. One of these pieces I sent with the patient to Dr. Fenwick, requesting him to be kind enough to compare it with the growth in the tongue, from which he removed a small slice. He reported to me that both growths consisted of a simple fibrous tissue. On several attempts at removal, the growth was found to be so unyielding that I was content with crushing it. This procedure generally resulted in atrophy of small portions. In the summer of 1869 the tumour had assumed a distinctly pedunculated character, and I removed a piece, about the size of a large pea, in the presence of Mr. Wordsworth. The patient attended from time to time, and small pieces of growth were generally removed at each visit. By this means the development of the growth was checked ; but 100 Consecutive Cases treated by the Author. 159 it was not entirely eradicated : it indeed showed a constant inclina- tion to extend. The fresh growth seemed to sprout from the ventricle, and I came to the conclusion that the neoplasm was partly situated in that cavity. December, 1870.—On the 10th of last month (November) I removed a piece about the size of a Barcelona nut. Half of it was white, with little tentacle-like projections, the other half was quite pink, and apparently composed of closely-packed columns. On the following Thursday, November 17th, I removed another piece quite as large, but black and sloughy in appearance on its free surface. On November 24th a third large fragment was evulsed. This piece was quite soft and friable. After each operation the vocal cord appeared almost cleared of growths; but at the next visit a new formation had taken place. The later portions removed were examined by Mr. Stephen Mackenzie, and pronounced to be in some parts fibrous, but in others to consist of the elongated, oat-shaped, granular, nucleated cells which characterize fasciculated sarcoma (Plate I. fig. 6). In some parts, also, abundant free nuclei were found, and in others simple epithelial cells. These specimens were also carefully ex- amined by several of my colleagues at the London Hospital. P.S. February gth, 1871.—I saw this patient after an interval of two months. He informed me that he had lately been in King's College Hospital with dropsy, under the care of Dr. Lionel Beale. There was a slight fresh development of the growth; and in the presence of Dr. Griffiths, of Swansea, and Dr. Roberts, of University College Hospital, I removed a piece the size of a haricot bean. Case LX.—Papillary Grozvth attached to the Right Vocal Cord; Treatment by Evulsion ; Cure. M. J., aet. 23, a nursemaid, applied at the Hospital for Diseases of the Throat, February 6th, 1868, on account of shortness of breath, which had existed fourteen months, and was believed to have originated in catarrh. On laryngoscopic examination, a long filiform growth was seen to be attached to the right vocal cord, near its anterior insertion ; the growth occasionally hung down in the glottis (Fig. 57), and at other times became lodged between the vocal cord and the ven- tricular bands (Fig. 56). At the second visit, February 13th, the 160 On Growths in the Larynx. growth was easily seized with common laryngeal forceps, and entirely removed, in the presence of Surgeon-Major Trestrail and Dr. Wilkie. Fig. 56. Fig. 57. On microscopic examination, the growth was found to consist almost entirely of squamous epithelium, one very large papilla only being found at the extremity of the growth. The patient was seen on the 27 th, when the larynx was clear, and there had been no recurrence of the dyspnoea. Case LXL—(Papillary) Grozvth on the Posterior Part of the Right Vocal Cord; Partial Evulsion; Improvement', Recurrence of Growth; Complete Evulsion ; Cure. Mrs. H., aet. 31, consulted me (by the advice of Mr. Harston, of Islington), February 8th, 1868, on account of aphonia of a year's duration. An examination with the laryngoscope showed a deeply fissured excrescence, about the size of a small raspberry, on the posterior part of the right vocal cord (Fig. 58). The growth Fig. 58. generally completely prevented the approximation of the cords, but sometimes it flapped up, and a feeble phonetic sound could be pro- duced. The throat being exceedingly irritable, and the lady very nervous, it was not till after several months' treatment with tube and common forceps that the greater part of the growth could be removed. A fairly good voice was recovered in June, but a small portion of the growth still remained. It will be readily understood ioo Consecutive Cases treated by the Author. 161 that constant operative treatment on the larynx is apt in nervous people to cause a certain amount of " wear and tear," and at the end of July, Mrs. H. seemed rather out of health. I therefore advised her to discontinue her visits, as may be seen by reference to the Medical Times and Gazccttc, vol. i. p. 632, in which I gave a short account of this case. At the time, I expressed an opinion that a further development of growth was probable; my anticipation proved correct. In the following spring the lady came again under my care, and after considerable trouble, the entire growth was com- pletely removed. In July, 1870, there was no appearance of any recurrence. Case LXIL—Papillary Grozvths on the Right Vocal Cord; Partial Evulsion ; Result unknown. Elizabeth F., aet. 57, a fish-hawker, came under my care at the London Hospital, in February, 1868, on account of cough and hoarseness, which had existed for four years. A laryngoscopic ex- amination showed a number of small whitish warty growths, form- ing a fringe along the entire length of the free edge of the right vocal cord. Two small fragments were removed at the second visit, but the patient did not apply again. The particles removed were of papillary structure. Case LXIII.—(Papillomatous) Grozvth in the Larynx; Treatment by Evulsion; Cure. Master Sydney D., aet. 10, was sent by Mr. Graves, of Gloucester, in February, 1868. His father stated that his voice had been quite natural until six months previously; at that time it became slightly hoarse, and for the last few weeks it had been entirely lost. He also suffered from shortness of breath on exertion, and had lately been awakened from sleep by attacks of suffocation. Fig. 59- Examination with the laryngoscope showed a white cauliflower- like growth, occupying almost the entire glottis (Fig. 59). On l62 Ou Growths in the Larynx. measurement, it was found to be five-eighths of an inch in length and half an inch broad. Never having known so large a growth to take place in so short a time, I examined most carefully into the previous history of the patient, and thoroughly satisfied myself that there had been no symptoms of laryngitis, or neoplasm, previous to the hoarseness, which had come on only six months before I saw him. My little patient was exceedingly nervous, so that at first nothing could be done. Two unsuccessful attempts to remove the growth were made under chloroform, and for a long time after he came under treatment, I had to be content with simply introducing the mirror, and getting a more or less partial view of the larynx. After some months he lost his fear, and the whole of the growth was ultimately removed with tube and common forceps. The voice, however, remained completely suppressed for several weeks after the larynx was clear of growth. This was probably on account of some congestion of the vocal cords. When restored, the voice remained harsh and disagreeable for three or four months, but it ultimately became perfectly clear. I saw this young gentleman in April, 1870, and there was not then either a sign of the growth, or the least abnormality in the strength and tone of the voice.— (Medical Times and Gazette, 1868, vol. i. page 632.) Case LXIV.—(Papillomatous) Growths on the Vocal Cords Partial Evulsion; Tracheotomy; Thyrotomyj Cure. I was called down to Norwood on April 21st, 1868, to see Miss B., aet. 66, who, the night previously, had suffered from a severe attack of dyspnoea. On further inquiry, I found that she had lately had frequent attacks of dyspnoea of a very severe character, and that she had lost her voice since the year 1854. She was in good general health, though suffering from slight cardiac weakness. On laryngoscopic examination, I found a large, bright red, lobulated growth, about the size of a gall-nut, blocking up the anterior two-thirds of the glottis (Fig. 60, and Plate II. fig. n). The insertion could not be accurately ascertained, but it was believed that the mass consisted, in point of fact, of two growths; springing from the anterior two-thirds of each vocal cord. By my recommendation, Miss B. came to town on April 29th. On six occasions after this date, I removed large fragments of ioo Consecutive Cases treated by the Author. 163 growth with forceps, through the mouth; but after operating on her on May 18th, so much inflammatory swelling took place, that I did not consider it safe to pursue this method of treatment any further. Fig. 60. The respiration being still embarrassed, I determined to have tracheotomy performed, and the remainder of the growth removed by thyrotomy. On the evening of May 21st she had another very severe attack of dyspnoea. The attacks came on whenever she began to doze, so that she could obtain but very little refreshing sleep. The next day, May 22nd, the symptoms being no better, I , requested my colleague, Mr. Couper, to perform tracheotomy, and afterwards to divide the thyroid cartilage, by vertical incision. Local anaesthesia having been first produced, Mr. Couper opened the trachea and inserted a tube. After allowing the patient a respite of half an hour, he then very carefully divided the thyroid cartilage in the median line. As, from repeated laryngoscopic examinations, I was so well acquainted with the exact situation of the growth, Mr. Couper requested me to effect evulsion. The larynx, therefore, being held open by means of a powerful retractor on each side, I seized the growth with short, strong forceps, and took the greater part of it away. I then cut the base more cleanly away with some blunt-pointed curved scissors. Mr. Couper finally united the alae of the thyroid cartilage with three silver sutures. The patient was relieved by the operation of all dyspnoea, and only complained of some soreness, and slight difficulty in swallowing for a few days. She seemed, to use her own words, " to get well without any trouble." Two of the sutures were removed a week after the operation, but one could not be seen, and sloughed out two months later. The patient entirely regained her voice, and remained quite well for two years and a half; that is, till the autumn of 1870. An appearance of recurrence began to be visible, with the aid of the 11 164 On Grozvths in the Larynx. laryngoscope, at this time, and the growth slowly increased in the winter of 1870-71. Owing to the irritability of the fauces and nervous condition of the patient, it is impossible to remove the growth from above; and if the neoplasm should attain a large size, the same operation will have to be repeated as was previously done. Case LXV.—Papillary Growth on the Ventricular Bandj Evulsion; Cure. J. G., aet. 34, a twine-spinner, first attended the Hospital for Diseases of the Throat, May 4th, 1868, on account of complete loss of voice, which had existed for two years. The laryngoscope revealed a small pink excrescence on the left ventricular band, about the size of a pea. The growth was demon- strated to Drs. Carlill, Sykes, Henry Roberts, and other gentlemen. No attempt at removal was made until June 19th, when the growth was easily seized by common laryngeal forceps. On microscopic examination, it was seen to consist of papillae, racemose glands, and some immature connective tissue. A week later I had the opportunity of showing Mr. John D. Hill, Mr. George Coles, and others, that the larynx was perfectly free: the man already spoke in a natural voice. Case LXVI.—(Papillary) Growth on the Right Vocal Cord; Evulsion; Cure. H. E. L., aet. 30, a waiter, was sent to me at the Hospital for Diseases of the Throat, June 4th, 1868, by Dr. Tatham, on account of aphonia, from which he had suffered for twelve months. The voice was generally suppressed, but at times there was a husky sound. There was no dyspnoea. Fig. 61. On laryngoscopic examination, a white, slightly-furrowed growth, about the size of a winter cherry, was seen occupying the anterior half of the right vocal cord (Fig. 61). ioo Consecutive Cases treated by the Author. 165 Several pieces were removed at various times, but it was not till July 30th that, in the presence of Mr. Balmanno Squire and Dr. Simpson, of Manchester, I was enabled to remove the whole, of the growth with common laryngeal forceps. The patient came to the Hospital in the following September, and I found the vocal cords entirely free from any irregularity. The voice was in every respect normal and of good power. Case LXVII.—(Papillary) Grozvths on the Right Vocal Cord; Partial Evulsion; Improvement. William R., aet. 36, a wool-packer, came under my care at the London Hospital in June, 1868, on account of loss of voice. He had been hoarse for rather more than a year, but had only lost his voice for three months. On making a laryngoscopic examination, two small growths were seen on the right vocal cord, and on attempted phonation, the vocal cords remained apart posteriorly to the extent of nearly a quarter of an inch. On the first attempt, the whole posterior growth was removed with the tube-forceps; but after repeated operations, the edge of the cord at its anterior half remained rough. The patient recovered a hoarse voice. In November, 1868, four months after the discontinuance of treatment, the patient remained in the same condition. Case LXVIII.—Papillary Growths on the Right Vocal Cord; Evulsion; Improvement; Recurrence in another part of the Larynx ; Evulsion ; Recovery of Voice. Master W. S., aet. 8, from Maidstone, was recommended to my care by Mr. Sankey, of that town, July 3rd, 1868, on account of loss of voice, which had existed two years. The child's mother stated that his voice first became husky, then gradually hoarse, and finally quite suppressed. The child had been always humoured a great deal, and was in consequence exceedingly difficult to examine. I managed, how- ever, at the first visit, to obtain a glimpse of the larynx, and to see a warty growth on the right side. Subsequently I ascertained that it was attached to the anterior portion of the right vocal cord (Fig. 62). The larynx was very small, and the epiglottis very overhanging. 166 On Growths in the Larynx. Many weeks elapsed before any instrument could be introduced into the larynx, and the child had to undergo a very laborious training : on each occasion ice had to be sucked for some time before even a laryngeal mirror could be tolerated. He was nearly six months under treatment, and during that time attempts at removal, often unsuccessful, were made almost daily. Ultimately the whole of the growth was removed, but the little boy's voice remained harsh and disagreeable. I saw him from time to time, without noticing any further alteration in the state of the larynx; but in the early part of the year 1870 I observed that there was a fringe of growths on the left vocal cord, and a cauliflower growth on the posterior wall of the larynx (Fig. 63). Fig. 63. The latter growth, though itself small, was large in proportion to the size of the child's larynx. In the course of some months the whole of the excrescences were removed, and the larynx was examined by Mr. James Keene in July, and pronounced to be perfectly free from any growths. On November 26th, 1870, I received the following report from Mr. Sankey:— " I am very glad to tell you that he has been steadily improving for the last three months : he is away at school; his voice has returned, although it is not free from huskiness yet, but improves from week to week." Case LXIX.—(Papillary) Growths on both Vocal Cords ; Tracheo- tomy and Division of Thyroid Cartilage; Relief of Dyspnoea ; Permanent Aphonia. Caroline M., aet. 12, was admitted into the Hospital for Diseases of the Throat, July 9th, 1868, but had been treated as an occasional loo Consecutive Cases treated by the Author. 167 out-patient for several years. The patient had suffered from con- stant loss of voice, almost since birth, and at intervals from most severe attacks of dyspnoea; and her father stated that several times an operation (tracheotomy ?) had been recommended. This case was even more difficult than the last; as, in addition to a very sensitive pharynx, the child had a most violent temper, and frequently would not submit to any treatment whatever. I, however, satisfied myself by repeated laryngoscopic examination, that the larynx was occupied by growths, situated on both vocal cords. It had been hoped that as the patient grew older, she would more calmly submit to treatment; but this idea proving incorrect, and the attacks of dyspnoea becoming more urgent, it was determined, with the consent of the parents, to perform tracheotomy, and after- wards thyrotomy. By this operation, which was performed by my colleague, Mr. George Evans, on July 15th, two warty growths, each about the size of a raspberry, were removed. They occupied the entire length of each cord. The same operation was performed as in Case LXIV., but chloroform was administered. The patient made a good recovery, and she has never since suffered from dyspnoea ; but her voice continues to be entirely suppressed. The larynx has been examined several times during the last two years with the laryngoscope; there is no recurrence of the growth, and no congestion of the mucous membrane. The aphonia appears to be due to diminished tension of the vocal cords, which however approximate perfectly. Case LXX.—Papillomatous Growth on the Right Vocal Cord; Evulsion ; Cure. Henry A., aet. 48, wool-packer, attended as an out-patient at the Hospital for Diseases of the Throat, July 9th, 1868, on account of loss of voice, which had existed for five years and a half. He had occasionally been able to sound his voice, but never for more than a day or two at a time. Laryngoscopic examination revealed a pedunculated warty growth, the size of a winter cherry, situated on the middle of the right vocal cord. At the second visit, in the presence of Drs. Jagielski, O'Keefe, Chatterton, and others, I succeeded in removing the whole of the growth, at the first attempt, with common antero-posterior forceps. The tumour was found, on microscopic examination, to be of a papillomatous character. 168 On Growths in the Larynx. I saw the patient in January, 1870, and found the larynx free and the voice normal. Case LXXI.—(Papillamatous) Grozvths on both Vocal Cords ; Treatment by Evulsion; Cure. Mr. S., aet. 27, a telegraph clerk at Malta, was recommended by several medical practitioners at that station to come to Eng- land, in order that he might consult me about his loss of voice. He had been hoarse for three years, but had only suffered from complete loss of voice during the last five months. He had latterly been troubled with shortness of breath, and by a continual hacking cough. His voice was of the greatest importance, as without it he would have been unable to retain his situation. On laryngoscopic examination, on July 13th, 1868,1 found a warty growth occupying the anterior two-thirds of the right vocal cord, and another smaller excrescence in the same position on the left cord (Fig. 64). The one on the right side overlapped that on the left, and it was only on attempted phonation, when the right growth was pressed upwards and outwards, that the outline of the left growth could be seen (Fig. 65). The extent of its attachment below was Fig. 64. Fig. 65. not ascertained until a later period, when the growth on the right cord had been removed. There was also another small growth, the size of a pea, on the posterior part of the left vocal cord. I recommended the patient to see me at the Hospital for Diseases of the Throat, where, on July 16th, I removed the whole of the growth on the right side with common laryngeal forceps, in the presence of Dr. Gray, of Oxford, and other gentlemen. After some months, the rest of the growths were removed, and the patient's voice entirely restored. I saw this patient in September, 1869, and his voice was then perfectly good, and the larynx free from any recurrence of the growth. 100 Consecutive Cases treated, by the Author. 169 Case LXXIL—(Papillary) Grozvth on the Right Vocal Cord; Treatment by Evulsion ; Great, Improvement. Thomas R., aet. 47, hawker, attended at the Hospital for Diseases of the Throat as an out-patient, on August 14th, 1868, on account of hoarseness and, at times, almost complete loss of voice. His voice had been bad enough to prevent him from following his occupation for six months, but he had suffered from sore throat for some years. He had formerly had constitutional syphilis. The case was first seen, during my absence from town, by Mr. Lennox Browne, who, on laryngoscopic examination, dis- covered a cauliflower-like growth, the size of a juniper-berry, on the middle of the right vocal cord. The whole of the mucous mem- brane of the larynx was thickened and congested. On my return to London, I succeeded in removing the growth with antero-posterior laryngeal forceps, at the second visit of the patient. On account of long-standing chronic hyperaemia, some dysphonia remained, but the man was perfectly satisfied with a loud and rather harsh voice. Case LXXIII.—(Fibro-cellular) Grozvth at Anterior Part of the Larynx; Evulsion; Restoration of Voice; (subsequent) Paralysis of the Abductor of the Left Vocal Cord ; Laryngotomy. (Death two years later.) Miss Annie S., aet. 18, came from Plymouth to be under my care, in October, 1868, on account of loss of voice, attended with difficulty of breathing. She stated that she had been quite well until two years previously, when " she first noticed that in singing, her voice would go off into a sort of squeak, which would last for a second, and then her voice would become natural again." This peculiarity was not noticed in her ordinary speaking voice till some time later, when it was observed that at times her voice would involuntarily assume a high falsetto tone. Changes of air always had the result of restoring the voice, for the first day after the change. Three months before she consulted me, however, the voice had become uniformly hoarse, and difficulty of breathing also had existed for about the same time. It was first observed at night, when she would wake up in her sleep with a sensation of choking. At first this happened only about once a week, but afterwards it occurred almost every other night. There was no pain in swallowing. 170 On Grozvths in the Larynx. She stated that her father's brother had died of consumption, but that the other members of the family were healthy. With the laryngoscope, a growth was discovered at the anterior commissure of the vocal cords, and on attempted phonation, it was seen that the neoplasm entirely prevented any movement of the left cord. Some of the growth was removed with tube-forceps, on the 14th of October ; but there was great difficulty, on account of considerable enlargement of the right tonsil, and it was found neces- sary to excise the hypertrophied gland. After this, the remainder of the growth was easily removed on the ist December. In January, the patient spoke in a clear voice, but the breathing was still difficult, and there appeared some defect in the abductive action of the left vocal cord. It was impossible to tell whether the paralysis had always existed, the position of the growth mechanically preventing its becoming apparent, or whether the loss of power came on subsequently to the removal of the neoplasm. The stridor increased so much in February and March, that on the 23rd of the latter month it became necessary to perform laryngotomy. This was done by Mr. Evans, and the patient made a good recovery. The abductor of the left cord remained permanently paralyzed, and the patient was unable to dispense with the tube. This patient came under treatment again eighteen months later, that is, in October, 1870, suffering from severe dysphagia, maras- mus, and hectic. She succumbed to these symptoms in the course of a few weeks. On post-mortem examination, there was found to be general disease of the laryngeal cartilages, and a fistulous communication between the pharynx and larynx. There was no sign of the growth. Case LXXIV.—Fibro-Epithelial Growth on the Left Vocal Cord; Evulsion ; Relief; subsequent Increase of Growth ; Tracheotomy ; Complete Evulsion of Growth through Mouth ; Cure. David L, aet. 41, labourer, came to me at the London Hospital, in October, 1868. He had been hoarse for thirteen years, and had latterly been short of breath. The patient, who was a very nervous, pale, puffy-looking man, admitted that he had been too much addicted to drinking. His fauces were relaxed and sodden. His uvula was elongated, and on laryngoscopic examination, a warty growth was seen attached along the whole length of the left vocal cord, and occupying the whole of the left side of the larynx. It ioo Consecutive Cases treated by the Author. 171 was white and cauliflower-like in appearance. A large portion of the growth was removed on three separate occasions, with common antero-posterior forceps, and the patient's voice improved so much that he discontinued his visits till December, 1869, when he re- turned with an aggravation of his former symptoms. He stated that he had lately suffered much from a violent cough and spitting of blood. With reference to the latter symptom, he said that on each of the two nights previous to his return to the hospital, he had brought up as much as two or three pints of pure blood. A most careful stethoscopic examination of the chest failed to discover any cause for this haemorrhage. Several portions of the growth were removed in March and April, 1870, and the patient discontinued his attendance at the hospital. In August, however, he applied again, with great dyspnoea. He visited the hospital several times, and was seen by my colleagues, Dr. Fenwick and Dr. Woodman. When I returned to town irt October, I found his breathing very much embarrassed, and at his urgent desire he was admitted into the Hospital for Diseases of the Throat. On October 10th I removed a small piece of growth with common laryngeal forceps. This was followed by considerable spasm. A few days later, that is on the 14th, I again removed a small piece of the growth. Scarcely had I left the hospital, when such extreme dyspnoea supervened, that it became necessary to perform tracheotomy. This operation was at once successfully done by Mr. Pugin Thornton. Since then, the patient has, of course, been free from dyspnoea, and I have since been able to remove the whole of the growth with my incisive forceps. The canula was removed in April, 1871, and there has been no fresh recurrence of growth. The patient speaks in a clear voice. The portions of the growth removed were examined by Mr. Stephen Mackenzie, and found to be of fibro-epithelial character. In some parts of the growth, nothing but cells could be found, whilst in others the structure was entirely fibrous, and again, in others, the two elements were blended together (Plate I. fig. 5). Case LXXV.—(Papillary) Grozvth on the Left Vocal Cord; Evulsion; Cure; Recurrence after a year; Evulsion a second time, and Cure. Wm. M., aet. 15, a page, was sent to the Hospital for Diseases of the Throat in November, 1868, on account of hoarseness, which had 23 172 On Growths in the Larynx. troubled him for nearly a year. There was no cough nor dyspnoea. On laryngoscopic examination, a growth about the size of a pimento berry was seen to be situated just behind the vocal process of the left vocal cord. The neoplasm was pale, smooth, and sessile. After several ineffectual attempts, I removed the whole of the growth, in the presence of Drs. Green away, Gourlay, and other gentlemen. The voice was quite restored. The patient returned in September, 1869, and on examination there was found to be a recurrence of the growth. In colour and size it resembled a millet-seed. On account of its small size, I had great difficulty in removing this second growth, and it was not till the sixth attempt, in the presence of Dr. Stage, of Copenhagen, and Mr. James Keene, that I was successful in seizing it. The boy's voice is now perfect. Case LXXVI.—(Papillary) Grozvth beneath Anterior Insertion of the Vocal Cords ; Treatment by Evulsion ; Cure. Mrs. Maria T., aet. 31, was sent to me, at the Hospital for Diseases of the Throat, in December, 1868, by Dr. Baumler, who kindly supplied me with the following history of her case, from his note-book, sometime after the patient had left my hands. " September 23rd, 1868.—Mrs. T. has always enjoyed good health, except during the last seven months, during which she has almost constantly been very hoarse, and has even, at times, lost her voice altogether. Temporary hoarseness has occurred for the last nine years, but, at intervals, her voice has become quite clear again. Since the hoarseness was permanent, she has gradually become weaker. At the time her voice first became affected her hair came out very much, but there was no sore throat nor any eruption in the skin. She had been married two years, and has one child. Eleven years ago she had an inflammation-of the eyes, which re- quired scarification. (Cicatrices and slight synechiae are still visible in the conjunctiva of the left eye.) " Present state, rather anaemic, although for the last two months she had taken mist, ferri perchlor. Voice without sound, but at times a somewhat clear note. " Velum palati and pharynx normal. Larynx also quite normal, with the exception of the anterior extremity of the right vocal cord and the adjoining anterior commissure, where a warty excrescence, the size of a lentil, is visible. It seems partly to grow out of the ioo Consecutive Cases treated by the Author. 173 vocal cord, and partly from the commissure (Fig. 66). On phona- tion it partly lies between the anterior part of the vocal cords, and Fig. 66. prevents their proper approximation. That part of the right vocal cord which adjoins the excrescence is a little red. "fannary ph, 1869.—Has been in the Hospital for Diseases of the Throat, and operated upon by Dr. Morell-Mackenzie. Voice still somewhat husky. The right vocal cord is somewhat injected; the prominent part of the growth has been removed, and only its broad base is now visible." I have only to add to this careful summary, that when the patient was admitted into the Hospital'I found another larger growth beneath the anterior insertion of the right vocal cord. The case was a difficult one for observation, and still more for treatment; but after being trained for a few days, the patient was able to submit to operative procedures, and the growth was so far removed that a slight unevenness only remained at the anterior surface of the cord. The lower growth was entirely removed. On the 24th of March, 1869, a laryngoscopic examination was made by Mr. Lennox Browne in my absence, who reported that " the larynx was quite normal, and that the voice was clear and resonant." Case LXXVII.—Papillary Grozvth on the Posterior Wall of the Larynx ; Evulsion ; Cure. Henry W„ aet. 27, a vocalist, applied as an out-patient at the London Hospital, in January, 1869, on account of hoarseness in ordinary speaking, and total loss of power in singing. He also complained of a cough, which was unaccompanied with expecto- ration. On laryngoscopic examination, a growth the size of a blackberry was seen springing from the posterior wall of the larynx. It was slightly irregular in outline, and of pink colour. The patient discontinued attending till May, when I had an opportunity of 174 On Growths in the Larynx. showing him to my class. In June the whole of the growth was removed at three sittings, with tube-forceps. The particles removed were found by Dr. Fenwick to consist of cylindrical papillae. In the following September the patient applied again at the Hospital on account of slight rheumatism. On laryngoscopic examination, the larynx was found to be perfectly healthy. Case LXXVIII.—Fibrous Grozvth on the Left Vocal Cord; Treatment by Evulsion ; Cure. Mr. B., aet. 42, a publican, consulted me in February, 1869, on account of shortness of breath and loss of voice. The symptoms were found, on laryngoscopic examination, to be caused by a large whitish, cauliflower, growth situated on the left vocal cord. Finding that the patient, who was a German, had formerly been under the care of Dr. Hermann Weber for another complaint, I proposed a consultation with that gentleman, and it was finally agreed between us, that I should attempt removal with the aid of the laryngoscope. Owing to the extremely irritable condition of the pharynx, I scarcely expected to be successful, and the probable necessity of division of the thyroid cartilage was discussed at the consultation. During the year 1869 I managed to remove several large pieces, and the patient became able to speak in a hoarse voice, and was entirely relieved of his dyspnoea. He was still seen by me occasionally in April, 1870, and there remained a little irregularity of the vocal cord. The ordinary laryngeal forceps, as well as those opening in the antero-posterior direction, and the tube- forceps, were used in this case. Since writing the foregoing, I have succeeded in removing the last fragment, and in October, 1870, the larynx was perfectly healthy, and the voice quite natural. The following microscopic report of pieces removed, April 23rd and 30th, was furnished me by my brother, Mr. Stephen Mackenzie :— "The growth submitted for examination was about the size of a dried pea, somewhat square-shaped, of pearly whiteness, and weighing one decigramme. " One side appeared to be that by which it was attached to the vocal cord—here it was marked by blood. This surface was smooth and uniform. Springing from its opposite side were a number of filaments, or fringe-like processes, packed very closely together. loo Consecutive Cases treated by the Author. 175 They were of about uniform thickness and length, quite white, and very tough, so that they were only detached from the surface from which they sprang with great difficulty ; a nail-brush would convey a very good idea of this growth, the ivory part representing the base from which the processes sprang, and the bristles the filamentous processes themselves (Fig. 67). Fig. 67. " a and b refer to the pieces of growth removed on April 23rd ; c to portion removed on April 30th." Examined under the microscope, there was found to be nothing. but white fibrous tissue, very dense in composition (Plate I. fig. 3). N o trace could be found of epithelium, elastic tissue, cells, or vessels. Case LXXIX.—Adenoma beneath the Anterior Insertion of the Vocal Cords; Treatment by Evulsion ; Cure. Alfred S., aet. ^^, a stonemason, first applied at the London Hospital early in March, 1869, giving the following history :— Two years previously he had become hoarse, but thinking that this was due to a cold, he paid no attention to it; the voice, how- ever, gradually became thicker and more husky. He suffered no pain, but was troubled with a constant dry cough. Nine months previously he had applied at the Victoria Park Hospital, where he had attended as an out-patient for three months. He had never spat blood, but had suffered from occasional attacks of dyspnoea, with stridor; he had not had syphilis, and his family history was good. On laryngoscopic examination, a small growth was observed be- neath the anterior commissure of the vocal cords (Plate III. fig. 6). This growth proved a very difficult one to extirpate, as the vocal 176 On Grozvths in the Larynx. cords became spasmodically approximated when any instrument was introduced within the larynx. A great variety of instruments were accordingly used. The first pieces were removed with the tube- forceps ; at a later period I used the common antero-posterior laryngeal forceps, and finally a portion was taken away with Stoerk's wire guillotine. On microscopic examination, the growth was seen to be almost entirely made up of an hypertrophied racemose gland, two sections of which are shown in Fig. 68. The time over which treatment extended was twenty weeks, and whilst under treatment he was seen by the Rev. Dr. Bell, M.D., and many medical practitioners. I have examined the larynx lately (April, 1870), and it is entirely free from any recurrence. The voice is perfectly clear, and there is no dyspnoea. Case LXXX.—Symmetrical (Papillomatous) Growths on the Vocal Cords ; Treatment by Evulsion ; Cure. Mr. W., aet. 60, a retired merchant, living in Manchester, con- sulted me April 21st, 1869. The previous history of the patient was that he had enjoyed tolerably good health until a year previously, when he had seen me, on account of hoarseness and a troublesome cough. I had then discovered nothing but congestion of the larynx and trachea, with a tendency to bronchitis. He had derived great benefit from local treatment, and had left me quite well. When, two months later, he wrote, telling me that he was suffering from his former symptoms, I advised him to place himself under the care of Dr. Simpson, of Manchester. That gentleman soon informed me that he noticed two growths on the vocal cords, and by my advice, for some weeks, he applied caustic solutions to the excrescences. This ioo Consecutive Cases treated by the Author. 177 treatment proving unavailing, Dr. Simpson recommended the patient to come to town to see me. On laryngoscopic examination, I found a small wart, about the size of a coriander-seed, symmetrically situated on each vocal cord, immediately behind the vocal process (Fig. 69). From the small size of the growths, and the fact that introduction of Fig. 69. any instrument generally caused violent cough, some difficulty was experienced in seizing them. At the end of a few weeks, however,' I effected evulsion with tube-forceps, and all the symptoms speedily disappeared. Case LXXXL—(Papillary) Grozvths on the Posterior Wall of the Larynx below the Glottis, with Paralysis of the Abductors of both Vocal Cords ; Laryngotomy and subsequent Removal of Grozvth through Tracheal Opening; Cure. Mary Ann D., aet. 51, a charwoman, applied at the Hospital for Diseases of the Throat, May 27th, 1869, on account of extreme difficulty of breathing, which had existed in a severe form for two years. She stated that thirty-six years previously she had suffered from a severe attack of measles, and that at the time her throat had been much affected, and had been lanced two or three times. Ever since her voice had frequently been suppressed during the winter months. Occasionally she was only hoarse ; at other times she could hardly whisper. These attacks sometimes only lasted for a week, but once she lost her voice for six weeks. Twenty-nme years ago she had small-pox, and since that time had never been strong; she had, however, married, and had brought up a family of six children. On admission, she was suffering from embarrassed and stridulous respiration ; she had a croupy cough, with scanty expectoration, and her voice was almost entirely suppressed ; she did not com- i78 On Growths in the Larynx. plain of pain, but of an occasional feeling of choking. She was very thin and haggard, and looked at least ten years older than her age. On making a laryngoscopic examination, it was seen, that, on inspiration, the vocal cords were very little abducted from the median line, but remained nearly approximated (Fig. 70). The larynx appeared otherwise quite healthy, and the vocal cords were perfectly white. It was judged to be a case of paralysis of the abductors, and the symptoms being somewhat urgent, laryngotomy was at once performed (May 30th). The patient experienced immediate relief when the canula was inserted. On June 7th, on making a laryngoscopic examination, it was observed for the first time that a small portion of a growth pro- jected upwards, between the vocal cords (Fig. 71). This con- Fig. 70. Fig. 71. dition having been verified on two or three occasions, an attempt was made to seize the growth with short curved forceps, introduced through the wound (the canula having been previously removed). The first trial was not successful; but on the 8th of June a growth f of an inch in its long diameter, by \\ inch in circumference, was removed. The patient was discharged, wearing the tube, on the 19th of July. She applied again in November, and on December 3rd she was re-admitted : the abductive action of the vocal cords being now perfect, and there being no trace of recurrence of the growth, the canula was removed. She suffered no inconvenience, made a good recovery, and is now (June, 1870) quite well, the respiration and vocalization being in every respect natural. In this case the growth appears in some way to have acted mechanically, and thus to have prevented the vocal cords being abducted by the crico-arytenoidei postici. The small space between the cords accounts for the circumstance that the growth (which was situated beneath them) was not seen till after the conditions had been altered by the opening in the windpipe. This patient during treatment was seen by Dr. Boddaert, of Ghent, Mr. Wordsworth, and many medical practitioners. 100 Consecutive Cases treated by the Author. 179 Case LXXXII.—Papillomatous Grozvths covering almost the entire Mucous Membrane of the Larynx; Treatment by Evulsion; Cure ; Recurrence ; still under Treatment. Rebecca L., aet. 21, was admitted into the London Hospital, on account of great difficulty of breathing, May 14th, 1869. Her mother stated that she had never been able to sound her voice, and that when she was a year old, it was noticed that she cried very hoarsely. The shortness of breath began to come on a year ago. She coughed up a great deal of phlegm, and made such a loud croupy noise in her sleep that no one could rest in the room with her. She first attended at the Victoria Park Hospital, and was after- wards in the Metropolitan Free Hospital for six weeks. Later still she was an out-patient at the latter institution, and had attended there till within six weeks of her admission into the London Hos- pital. On admission, the patient was found to be suffering from considerable dyspnoea and stridulous breathing, and it was thought that tracheotomy would be necessary. She passed a very bad night, being obliged to sit up all the time, but obtained some relief towards the morning from benzoin inhalations. The next day I saw her for the first time, and on laryngoscopic examination I found growths on both vocal cords, entirely occluding both cords and ventricular bands. The larynx was exceedingly small, not larger than that of a child eight years old, and I had the greatest difficulty in introducing any instrument into the larynx. I however succeeded with tube-forceps, on the first' occasion, in removing several pieces, which, in the aggregate, were as large as a pea. After some weeks all the growths had been removed, with the exception of a very small piece on the right vocal cord. This last remnant proved a great difficulty; the pharynx was so sensitive that the patient was obliged to suck ice for nearly an hour before she could be operated on; the laryngeal aperture was, as observed, extremely small, and the base of the growth proved to be very hard. However, at the latter end of April the voice commenced to be dis- tinctly phonetic—the dyspnoea had disappeared long since—and in May I had the satisfaction of seeing that the larynx was entirely free of growths, and of hearing a clear and even agreeable voice. In the spring of 1870 a slight recurrence of growth took place on the right ventricular band, and the patient is still under treatment. Portions of the growth removed were examined under the micro- 24 i8o On Grozvths in the Larynx. scope by my brother, Mr. Stephen Mackenzie, who reported that they consisted of large papillae covered with several layers of squa- mous epithelium (Plate I. fig. i).—(Case briefly reported in Lancet, vol. i., 1869, page 229.) Case LXXXIII.— Papillomatous Grozvths on the Right Vocal Cord and Under Surface of the Epiglottis; Partial Evulsion; Im- provement. Eliza B., aet. 51, came under my care at the London Hospital, May, 1869, on account of hoarseness and dysphagia, which had existed for four years. With the aid of the laryngoscope, it was seen that there were two growths in the larynx : one, the size of a large pea, was attached by a broad base on the right vocal cord; the other, not larger than a grain of wheat, grew from the under surface of the epiglottis. The patient had never had syphilis, and there was no evidence of phthisis. The growth on the epiglottis was removed at the second visit with common forceps, and the greater part of the growth on the right vocal cord a few days later. These portions, examined by Dr. Fenwick, were pronounced to be simple warty growths. The result of treatment is unknown in this case, as the patient discontinued attendance after the second visit. There can be little doubt but that great improvement must have taken place. Case LXXXIV.— Papillary Grozvth on the Left Vocal Cord; Treatment by Evulsion ; Cure. Emma P., aet. 2r, servant, was sent up to the London Hospital from Maidstone, in June, 1869, on account of great difficulty of breathing. She had had three attacks of strangulation, each of which had come on during the night. The first attack occurred in December, 1868. She could only lie down on her right side, and was obliged to sleep with her hand under her neck. If, whilst asleep, her hand slipped away, she always woke with difficulty of breathing. Occasional loss of voice had been noticed as early as October,, 1867, and from that time till the following April she could speak hoarsely by making a great effort. Since April, 1868, she had been unable to sound her voice at all. ioo Consecutive Cases treated by the Author. On laryngoscopic examination, a smooth, pale, growth was seen to be growing from the anterior two-thirds of the left vocal cord. It appeared to be as large as a common hazel nut, and at the first visit a piece was removed, which was believed to be the whole growth. In the following week, however, it was seen that a piece as large as a gall-nut still remained attached to the under surface of the left cord, and in addition, there was a growth the size of a small pea attached to the centre of the right cord. A large piece was again removed, and subsequently, as many as a dozen pieces have been taken away. Tube-forceps, common forceps, and Stoerk's wire-guillotine were all used in this case. It is worthy of note, that this case was one of those rare instances in which pain attended the operation. The patient always complained of severe pain in the ears after each attempt at removal. Although the symptoms greatly improved, the progress of the case was for some time very disappointing. No sooner was one neoplasm removed, than another, situated lower down, was revealed. In August, 1870, the right cord was quite clear, but a small portion of growth remained low in the larynx, beneath the left cord. The patient had entirely lost all symptoms of dyspnoea, and her voice was quite clear. On December 13th, 1870, I saw this patient after an interval of nearly four months. The remnant on the left cord appeared to be hanging by a mere thread, and was easily removed. I had the opportunity of showing her a few days later to Dr. Elsberg, of New York, who examined the larynx, and agreed with me that it was then quite clear ; the patient spoke in a perfectly natural voice. Case LXXXV.—Cystic Tumour on the Epiglottis ; Puncture and Evacuation of Contents ; Cauterization ; Cure. M. W. W., aet. 22, farrier, applied at the Hospital for Diseases of the Throat, June 28th, 1869, on account of difficulty of swallowing, and slight hoarseness. He stated that he felt a constant desire to clear his throat, which seemed always full of phlegm. Swallowing was not painful, but difficult; and food, especially fluids, constantly went the wrong way. His voice was slightly husky. He stated that he had been constantly exposed to inclement weather, and that his symptoms had existed about six years. On examination with the laryngoscope, a large globular swelling, 182 On Grozvths in the Larynx. the size of a cherry, was seen on the upper surface of the epiglottis (Fig. 72, and Plate III. fig. 2). This swelling projected through the under surface of the epiglottis, so as to almost entirely hide the right half of the larynx (Fig. 73, and Plate III. fig. 1). A few days later, Fig. 72. Fig. 73. I made a free opening in the tumour with my unguarded laryngeal lancet, in the presence of Dr. Gore Ring and others. There was a free discharge of steatomatous-like matter, with a small quantity of glairy fluid and blood. On July 26th there was not the slightest sign of the tumour, nor even of the puncture. Cask LXXXVI.—(Papillomatous) Growth at the Anterior Commis- sure of the Vocal Cords; nearly Complete Evulsion; Great Improvement. Mr. J. Y., aet. 43, a farmer, was sent to me by Dr. Lewis, of Basingstoke, in September, 1868, on account of an altered voice, and an extremely disagreeable sensation in the windpipe. A laryngoscopic examination showed considerable congestion of the lining membrane of the larynx, and diminished mobility of the vocal cords. Local applications, of an astringent character, were repeatedly made to the throat for five weeks, and the patient left, having obtained, as he stated, considerable relief. Rather less than nine months afterwards, however, he applied to me again, on account of loss of voice and frequent attacks of suffocation ; and on making a. laryngoscopic examination, I dis- covered a large, irregular, lobulated growth, about the size of a raspberry, beneath the anterior commissure of the vocal cords, blocking up half the space of the glottis. Notwithstanding that the patient was an exceedingly nervous man, and did not tolerate the laryngoscopic examination at all readily, in the course of a month I removed several pieces of growth ; in the aggregate these would have made up a growth about the size of a large cherry. They IOO Consecutive Cases treated by the Author. 183 were taken away partly with tube-forceps, and partly with Stoerk's e'eraseur. At the end of July, when I left town for my vacation, there was still a small portion of growth remaining, but the patient was able to breathe without difficulty, and could sound his voice. In January, 1870, I heard from him to the following effect: "My voice is still very weak, but I can talk a little in the natural voice" (The italics are his own.) Case LXXXVII.—Epithelioma on the Right Vocal Cord; Tra- cheotomy and Thyrotomy; Constant Development of Growth ; Death. Mr. John S., aet. 47, silversmith, consulted me September 18th, 1869, on account of hoarseness, attacks of suffocation, and slight difficulty in swallowing. The patient was a stout, thick-set man, but his countenance was pale and anxious, and his pulse feeble. He stated, that for the last five years his breathing had been short, but he attributed this symptom to his increasing stoutness. Four months previously, however, he had been alarmed by a violent attack of suffocation during the night. These attacks came on more fre- quently, and a month later his voice became hoarse. Fie also suffered from most violent paroxysms of cough. His digestion was not good, but his appetite was almost voracious ; in fact, he really ate as much as two or three ordinary men. After his meals, his difficulty of breath- ing was always much increased. He had received some general treat- ment, but without relief. On examining the throat, the pharynx was seen to be greatly relaxed, and the uvula elongated. The fauces were so irritable, that a mere inspection even of these parts caused an inclination to retch. After some difficulty, however, I succeeded in making a successful examination of the larynx, and discovered a red cauliflower-growth, the size of a cherry, projecting from the right vocal cord (Fig. 74) : the mucous membrane gene- rally was congested and relaxed. It was only after seeing the 184 On Growths in the Larynx. patient several times, that he permitted me to make any attempt at removal of the growth, and even then he was so nervous and restless, that my efforts were unsuccessful. On the third occasion, however (September 27 th), I succeeded in removing a portion about the size of a large pea. The piece was removed with very slight force—not more than is commonly necessary in eradicating soft neoplasms growing on mucous mem- brane, but the patient complained of extreme pain, and on this account obstinately refused any further laryngoscopic treatment. Two days later (29th) Mr. S. took cold, and his breathing became much worse. As the symptoms were urgent, and the patient was willing to have an operation performed under chloroform, tracheotomy and thyrotomy were proposed and acceeded to. Accordingly, on October 3rd, Mr. Wordsworth opened the trachea. The operation was attended with considerable difficulty, on account of the shortness of the neck and the extraordinary amount of fat in front of the windpipe. In addition to this, the patient bore chloroform very badly, and showed marked signs of cardiac syncope. On this account, it was not thought safe on that occasion to perform thyrotomy. The patient did fairly well after the operation, and a fortnight later a vertical incision was made through the thyroid cartilage, and several large pieces of growth were removed from the larynx; the parts were afterwards brought together with silver sutures. The wound healed, but the patient was advised to continue to wear the tube for a time. As the immediate result of the operation, it may be stated that the dyspnoea entirely ceased, that the swallowing was effected with ease, and that the voice, though hoarse, became for a short time distinctly phonetic. The patient, however, continued to suffer from attacks of coughing, which he did not at all attempt to restrain. At the beginning of December, it was noticed that the weak granulations, commonly seen beneath the shield of a canula, when a tube has been worn for a few weeks, were larger and more numerous than is usual. This condition was thought to be sufficiently accounted for by the fact that the patient was so penurious, that he not only refused proper—that is, sufficiently frequent—medical attendance, and nursing, but he even grudged clean linen and changes of clothing. Thus it happened that there was always a certain amount of moisture around the canula. In spite of the application of solid nitrate of silver to the exuberant 100 Consecutive Cases treated by the Author. 185 papillre, and the frequent use of powdered oxide of zinc, and of various other remedies, the vegetations extended in all directions. He began also to show signs of depression, though his appetite was still good, and he slept fairly well. Laryngoscopic examinations had been made from time to time, and in January, 1870, it was first observed, that there was some recurrence of the growth. In the beginning of March the neoplasm was seen to rise above the level of the ary-epiglottic folds, and to block up the entire larynx (Fig. 75). The patient now suffered from Fig. 75. frequent suffocative attacks of coughing, apparently on account of the tube becoming obstructed. Repeated examinations of the canula during these attacks showed that it was not blocked up by mucus, and it was judged that the growth had extended downwards, and obstructed the lower end of the canula. The patient died during one of these attacks in the night of May 10th, 1870. On making a post-mortem examination, it was' found that the whole of the interior of the larynx was blocked up by an enormous cauliflower excrescence, which extended from the level of the ary- epiglottic folds, downwards, for more than four inches, thus reaching quite an inch below the orifice in the trachea, made in tracheotomy. It likewise penetrated to the base of the right ary-epiglottic fold, and had extended into, and enlarged, the right hyoid fossa (Plate IV. figs. 2 and 3). The growth extended along the track of the canula to the outside of the neck, and formed a thick fringe, an inch and a half in width, around the orifice of the tracheal opening; so that the supposed granulations under the canula shield proved to be neoplasms of exactly similar formation to the growth in the larynx (Plate IV. fig. 1). The luxuriant growth of the new formation in this case pointed to its being otherwise than of benign character, and its microscopic examination illustrates the extreme difficulty of arriving at accurate conclusions concerning the histology of these 186 On Grozvths in the Larynx. tumours, even when the entire growth is brought under observation. The specimen was examined by several eminent microscopists, and was at first reported to be a simple papilloma. On another examination, fibrous tissue was found to be largely developed, and it was pronounced fibro-cellular. Still later, my brother, Mr. Stephen Mackenzie, discovered some nested cells (laminated cap- sules of Paget). One of these is depicted in Plate I. fig. 8, and from the extreme importance of this element, the case must un- doubtedly be placed in the category of carcinomatous growths, and be considered as epithelioma. The whole surface of the growth was covered by papillomata. The fact that during life it was believed to be, and was treated as, benign, had led me to include it amongst these cases; and having done so before repeated microscopic examinations had succeeded in discovering any cancer elements, I did not think it fair to exclude it afterwards. Case LXXXVIII.—Adenoma on the Under Surface of the Epiglottis ; Tracheotomy ; Removal of Grozvth by Ecraseur ; Recovery. A retired Indian officer, aet. 51, applied to me on October 12th, 1869, on account of an exceedingly troublesome cough, slight hoarseness, and occasional dysphagia. The symptoms had com- menced about a year before. Twenty years previously the patient had suffered from syphilis. On making a laryngoscopic examination, there was found to be superficial ulceration, with slight thickening of the left side of the epiglottis (Fig. 76). The ulceration yielded rapidly Fig. 76. to treatment, consisting of iodide of potassium and the local ap- plication of mineral astringents. On discontinuance of the remedies, however, there was a great disposition to recurrence, and the patient exhibited a decided catarrhal tendency. Under these circumstances, on November 6th, I recommended him to pass the winter at roo Consecutive Cases treated by the Author. 187 Cannes. I received favourable reports of him for some weeks, but early in January, 1870, I heard from Dr. Frank that a laryngoscopic examination, made by himself and Dr. Wagner, of Konigsberg, had discovered " a large sarcomatous neoplasm " on the under surface of the epiglottis. These gentlemen recommended his immediate return to England, in order that the growth might be removed. On January 9th, 1870, I made a laryngoscopic examination, and found an irregularly mammillated growth, of a pale colour, about the size of a cherry (Fig. 77, and Plate III, fig. 4). On Fig. 11, several occasions lately, the patient had suffered from severe dys- pnoea. I therefore thought it advisable to have tracheotomy per- formed before attempting to remove the growth, and the windpipe was opened on the 14th of January by Mr. James Adams. The patient took cold soon after the operation, and suffered from rather severe bronchial catarrh. It was not therefore till March 6th that I proceeded to extirpate the tumour. Chloroform was admin- istered by Mr. Clover, and the growth was removed by means of my wheel ecraseur. The tumour weighed fifty grains, and was of the dimensions given in the annexed drawing (1 inch by three-quarters of an inch (Fig. 78, and Plate III. fig. 5). This specimen was ex- Fig. 78. hibited at the Pathological Society, and referred for investigation to the Morbid Growth Committee. The Sub-Committee appointed to examine the specimen, considered it a case of "adenoid car- cinoma" (Medical Times and Gazette, July 16th, 1870), but their 25 188 On Grozvths in the Larynx. report was not confirmed by the full committee, and does not appear in the Transactions, vol. xxi. p. 51. On the next day it was seen that the epiglottis was quite clear, except a small sloughy surface at the outer angle. The swallowing improved immediately, and the voice was also much better. Ten days later I noticed a slight irregular ulceration on the ventricular bands, but this rapidly yielded to treatment. In May, 1870, the breathing being good and the voice natural, the tube was removed, and the patient shortly afterwards went down to the seaside. Un- fortunately, however, at the end of a month, he took a severe cold; acute laryngitis supervened, and it became necessary to perform tracheotomy a second time. The patient still wears the tube. The pathological interest of this case depends on the extreme rapidity of the production of the neoplasm, and on its possible dependence on the syphilitic dyscrasia. Case LXXXIX.— Vascular Tumour in the Right Hyoid Fossa; Treatment by Evulsion ; Cui-e. Captain V., aet. 35, of the Royal Marines, was sent to me in December, 1869, by Dr. Smyly (of Dublin), a well-known laryngo- scopist, who had previously examined him with the laryngeal mirror. The patient complained of an uneasy tickling sensation in the throat, which had come on in the previous summer, when he had hay fever. The voice was normal. On laryngoscopic examination, a growth, the size, colour, and configuration of a ripe blackberry, was seen in the right hyoid fossa (Fig. 79, and Plate II. fig. 12). Several Fig. 79- attempts were made at removal, but, owing to the extreme hardness of the growth, it was not entirely removed till January 21st, 1870. Incomplete evulsion was effected with tube-forceps, and the base of the growth was excised with cutting forceps. The operation was attended with more haemorrhage than is usual. ioo Consecutive Cases treated by the Author. 189 and the patient informed me that for some hours after leaving my house slight bleeding took place. The growth, on removal, had lost its black colour, and was of a rather bright red hue. On section, its appearance to the naked eye was compact, and its colour almost white. On microscopic examination, it appeared to consist of fibrous tissue of an exceedingly close and matted character. No blood-vessels could be discovered, nor did it contain any blood ; but numerous elongated nuclei were seen. The appearance indeed closely corresponded with the description of a case of " venous vascular tumour" removed from the thigh of a patient by Sir William Lawrence. Mr. Paget's remarks (Op. cit., p. 583), in the case referred to are so entirely applicable to my specimen that I feel I cannot do better than quote them :—" The obscurity of the micro- scopic appearances was due to the tenacity with which the blood- vessels were imbedded in the elastic fibrous or nucleated tissue ; it seemed impossible to extricate complete vessels ; and one, obtained by dissection, only fragments of their walls, confused with the inter- mediate tissues." Case XC.—Papillary Growths above and below the Anterior Commissure of the Vocal Cords ; Treatment by Evulsion; Cure. Thomas W., aet. 44, labourer, presented himself as an out-patient at the Hospital for Diseases of the Throat, January 20th, 1870, on account of hoarseness, which had existed nearly twelve years. He felt no pain, but always had a sense of tightness about the throat. He had had syphilis fifteen years previously. On laryngoscopic examination, both vocal cords were observed to be in a state of chronic inflammation, and their edges were very Fig. 80. irregular. From the anterior commissure a long narrow growth hung down between the cords. It was almost white, and somewhat resembled a nasal polypus in appearance,^though less transparent (Fig. 80). 190 On Growths in the Larynx. Repeated operations, resulting in removal of one or more pieces, were made on various occasions. Once in the presence of Dr. Thorowgood, a piece five-eighths of an inch long, and one-eighth in breadth, was removed ; but at each succeeding visit, there seemed to be as much growth left as before. This was on account of succes- sive portions of growth becoming visible below the glottis, as other portions were removed by evulsion. Altogether as many as 22 pieces were removed, and ultimately the whole growth was eradi- cated ; after astringents had been applied for some weeks, the chronic congestion was greatly diminished, and the patient recovered a good voice. Microscopical examination showed that the growth consisted of the ordinary elements of a benign papilloma. Case XCI.—(Papillomatous) Growths on Both Vocal Cords; Treatment by Evulsion ; Cure. Henry C, aet. 47, a wine-bottler, attended as an out-patient at the Hospital for Diseases of the Throat, on account of loss of voice, of six months' standing. On examination with the laryngoscope, a large growth was seen, occupying the whole length of the right vocal cord, and another smaller one on the left cord. Both cords were very irregular (Fig. 81). Fig. 81. The patient was exceedingly nervous, but his employers were good enough to allow him wine ad libitum before each visit to the hospital. With the aid of this stimulant, and ice for half an hour before the operation, he was able to undergo treatment. I suc- ceeded very early in the history of the case in removing the larger portion of the growth from the right vocal cord, Surgeon-Major Wyatt, Dr. Stage, of Copenhagen, and Mr. Edwin Peacock, of Birmingham, being present. Common antero-posterior forceps were used. ioo Consecutive Cases treated by the Author. 191 The growths on the left vocal cord were more difficult to remove, and many attempts were unsuccessful. Finally, however, on May 5th, 1870, the larynx was examined in the presence of Dr. Farquhar, and seen to be clear; but the voice, though phonetic, still remained slightly gruff. This was no doubt due to the long-standing hyperaemia of the mucous membrane of the larynx. In this case there were in all ten operations, and six pieces were removed, amounting en masse to a growth the size of a cherry. Case XCII.—Benign Epithelial Growth on and below the Left Vocal Cord; Treatment by Evulsion ; Cure. Anne M., aet. 48, haberdasher, attended the Hospital for Diseases of the Throat on February 3rd, 1870, by recommendation of Mr. Kennedy, of Stratford. She stated that she had suffered " from loss of voice on and off for twenty-four years." The origin of the aphonia was supposed to be exposure in a snow-storm ; for on the following day she lost her voice, and since that time it has never properly returned. Latterly it had been completely suppressed. On laryngoscopic examination, it was seen that the left vocal cord and the mucous membrane beneath it, for half an inch, were covered by an uneven growth, which, though occupying a large area, did not appear to project more than an eighth of an inch beyond the level of the mucous membrane. It was some time before I was enabled to remove any portion ; but on April 25th, in the presence of Dr. Haden, as well as those other gentlemen who were attending the practice of the hospital, I succeeded with forceps in scraping away and detaching an irregular growth, about the size of a split almond. Three days later I found that the growth had been completely removed. There still, however, remained considerable hyperaemia of the left vocal cord. On microscopical examination by Mr. Stephen Mackenzie, " the growth was found to consist of simple epithelial structure. It was made up of cells irregular in size and shape, some being round, others oval, caudate, and fusiform. The nuclei were very distinct, and most of them large; some cells contained more than one nucleus, and a few of them were undergoing dichotomous division. All the cells were very granular." 192 On Grozvths in the Larynx. The patient has now (September, 1870) a good voice, though it is not perfectly clear. Case XCIII.—(Papillomatous) Growth on the Left Vocal Cord; Treatment by Evulsion ; Cure. Robert W., aet. 30, engine-driver, applied as an out-patient at the Hospital for Diseases of the Throat, March 3rd, 1870, on account of hoarseness, which had existed for eighteen months. He attributed his symptoms to exposure to draughts, and sudden changes of tem- perature. On examination with the laryngoscope, a smooth but slightly mammillated growth was seen attached to the left vocal cord. It was easily removed at the second visit, on March 7th, in the presence of Dr. H. Hubbard and others. On April 21st, there having been no return of the growth, and the voice being perfect, the patient was discharged cured. In July he was examined by Mr. Keene, who agreed with me that the larynx was quite healthy. Case XCIV.—(Papillary) Growth on the left Vocal Cord; Treatment by Evulsion ; Cure. Mary Anne R., aet. 35, a gilder's wife, attended at the Hospital for Diseases of the Throat, March 7th, 1870, on account of loss of voice. She attributed the aphonia to exposure to cold five years previ- ously. Since that time she had been frequently hoarse for two or three months at a time; and during the last year her voice had been entirely suppressed. For the last ten weeks she had also suffered from shortness of breath. On examination with the laryngoscope, a smooth, pea-like growth was seen, attached by a broad base to the left vocal cord. On March 24th it was entirely removed with common antero-posterior forceps, in the presence of Mr. Keene and Dr. Stage, of Copenhagen. A fortnight later, the voice was natural, and the larynx, examined by each of the above-named gentlemen, was seen to be quite free from any sign of growth. ioo Consecutive Cases treated by the Author. 193 Case XCV.-—Sarcomatous Grozvth on the left Ventricular Band; Treatment by Evulsion ; Cure. Susan W., aet. 43, a coachman's wife, attended as an out- patient at the Hospital for Diseases of the Throat, March 7th, 1870, on account of complete loss of voice. She stated that she had been subject to sore throat whenever she took the slightest cold for the last twenty-three years, and that her voice had been affected, with but very slight intermissions, during the whole of that period. For the last year, she had been per- manently hoarse, and for the last four months her voice had been entirely suppressed. She complained of soreness and a pricking pain, "as if a bone were in her throat." Swallowing was painful, and her breathing was short on the least exertion. Lately, she had awoke in the night with attacks of choking. On laryngoscopic examination, a large irregular growth was seen, on inspiration, to be attached to the right ventricular band, entirely occupying the right half of the larynx, with the exception of a very small portionof the right vocal cord, at its anterior insertion (Plate HI. fig. 7). On attempted phonation, the growth projected across the left vocal cord, and occupied two-thirds of the area of the larynx (Plate III. fig. 8). The colour of the growth was red, like that of the surrounding mucous membrane. On the 17th of March the first attempt at removal was made, and on this occasion common laryngeal forceps were introduced into the larynx three times. On the first introduction of the instru- ment, one large piece was removed, and subsequently two smaller fragments (Plate III. fig. 9), and the voice became at once per- ceptibly better : it was, however, impossible on this occasion to see the condition of the larynx, on account of the slight haemorrhage which took place. On the 24th the voice was perfectly phonetic, and the larynx quite free of growth, the only remaining symptoms being a slight irregularity of the right ventricular band, at the posterior part of the larynx, and some congestion of the right vocal cord. This subsided, and a week or two later, the patient was discharged, cured. This case, the facts of which are known to Dr. Carre, of Black- heath, was frequently examined, both before and after treatment, by 194 On Grozvths in the Larynx. Dr. Stage, of Copenhagen, Mr. Keene, Mr. Peacock, and other gentlemen. Microscopical examination of this growth by Mr. Stephen Mac- kenzie showed that " it consisted of extremely long fusiform cells. Some of the cells were oat-shaped, and some more spherical; but all had a tendency to elongation (Fig. 82). The cells, for the most part, Fig, 82, possessed pretty distinct, round or oval nuclei, and the cell-contents were granular, and approached a fatty condition ; but it should be mentioned that the specimen had been immersed in spirit for a few days before it was examined. In some parts of the neoplasm there was a small amount of squamous epithelium/' Case XCVL—Papillary Growth on the Posterior Wall of the Larynx ; Treatment by Evulsion ; Cure. Sarah Ann S., aet. 27, a sewing-machine worker, came under my notice at the Hospital for Diseases of the Throat, March 14th, 1870. She stated that she had suffered from hoarseness for the last two years, and from great soreness in the throat for the last twelve months. Her voice was sometimes phonetic, though always now harsh and unpleasant, and occasionally it subsided into the merest whisper. During the last nine months she had once or twice spat about a teaspoonful of blood. On examination, a large indurated specific ulcer was observed on the under surface of the tongue. There was no appearance of disease in the pharynx, but in the larynx was seen a pink growth with dentated edges, springing erect from the outer 100 Consecutive Cases treated by the Author. 195 arytenoid fold. The appearance was somewhat similar to a small cock's comb (Fig. 83). The right vocal cord was slightly irregular, and the larynx generally was congested. Examination of the chest gave no signs of pulmonary disease. The patient was treated for some weeks for the congestion by inhalations, and by iodide of potassium ; and the ulcer on the tongue was touched twice a week with solid nitrate of silver. It was not till April 25th that I attempted removal of the growth. On this occasion, in the presence of Mr. Keene, Drs. Collum, Stage, and others, I removed the growth. The patient was seen on the 20th May, when the larynx was perfectly clear, and the voice normal. The ulcer on the under surface of the tongue still remained. On microscopic examination, the neoplasm was found to be of simple papillary structure. Case XCVII.—Fibroma on the Posterior Wall of Larynx ; Treatment by Evulsion ; Cure. Emma B., aet. 29, a butcher's wife, applied at the Hospital for Diseases of the Throat, March 31st, 1870, complaining that since July in the previous year her voice had always been lost in damp weather, and that at all times she suffered great pain in speaking, and had to make a great effort in order to sound her voice. After using her voice for a short time, she experienced a great sense of fatigue. There was no dysphagia. On laryngoscopic examination, a pale pink, slightly uneven, growth was seen springing from the posterior wall of the larynx (Fig. 84, and Plate III. fig. 10). The patient was not in good general health when she came to the Hospital, so that it was not till the 2nd of May that, in the presence of Dr. Webb, of Cincinnati, 26 196 On Grozvths in the Larynx. U.S.A., and Dr. Bowditch, I attempted removal of the growth. This was easily effected in two operations, with common laryngeal forceps. Fig. 84. On microscopical examination, the neoplasm was found to consist of a compact fibrous structure, the fibres interlacing in every direc- tion. The whole growth was enclosed in an epithelial investment, consisting of about seven layers of cells. Case XCVIII.— Congenital (?) Papillary Grozvths in the Larynx; Tracheotomy; Death. Thomas M., aet. 2 years and 4 months, the child of a lighterman, was brought to the Hospital for Diseases of the Throat, May 7th, 1870, by his parents, who gave the following account of him :— From the first moment of birth he had never cried like other babies, but his voice had always been " croupy." For the last six or eight months his breathing had been gradually getting worse, but he had never breathed quite freely since birth. He could not lie down, but was always put to bed with his head very high; he was very restless in his movements during sleep, and woke frequently. The child was a fine rosy boy, well nourished, and full grown. On trying to make him talk, it was observed that the voice was entirely suppressed, except occasionally, if he was excited, when a slight gruff vocal sound was emitted. His breath- ing was very noisy and stertorous. There was, however, but slight cough, and no expectoration. His father and mother were both healthy. They had one other child, eight months old, whose voice was quite lusty. A laryngoscopic examination in this case was attempted, but IOO Consecutive Cases treated by the Author. 197 with purely negative result, the child being quite unmanageable; I, however, had no hesitation in expressing opinion that the case was one of congenital growth in the larynx. The complete aphonia and difficulty of breathing seemed to indicate that the growth was of considerable size, and probably in the immediate neighbourhood of the vocal cords. On May 9th the child entered the hospital, and his respiration becoming every hour more embarrassed, tracheotomy was performed on the 10th. The tube was inserted very quickly, with but little haemorrhage. The child seemed to rally for a time, swallowed stimulants and nourishment, and took notice of his father, whom he would not allow to leave him. Eight hours after the operation, however, the respiration was observed to become very feeble, though there was no stridor or dyspnoea. He sank 12 hours after the operation, and it was observed that he had never coughed nor made any effort to expel mucus from the tube. On post-mortem examination, the diagnosis was at once verified, the glottis being almost completely blocked up with growth. Both vocal cords, the right ventricular band, and half of the left band were entirely covered by a cauliflower mass of warty growths (Plate V. fig. 1), which, on microscopic examination, were found to be of a simple epithelial character (Plate I. fig. 2).—British Medical fournal, 1870. Case XCIX.—Fibro-Cellular and Myxomatous Grozvths on both Vocal Cords; Treatment by Evulsion ; Cure. Mr. L. T, aet. 27, the son of a medical practitioner at Devon- port, consulted me, May 18th, 1870, on account of hoarseness, which had existed for two years. The patient was in excellent health, and there was no other symptom of disease. His voice, when I saw him, was distinctly phonetic, but he said that it was always shrill or hoarse, and that he had never been able to sing. The breathing was not in the least embarrassed, even after run- ning or other active exertion. On laryngoscopic examination, a very large, pink, lobulated, growth was seen occupying the anterior three-fourths of the right vocal cord, and in deep inspiration projecting across the left vocal cord. The portion of the growth furthest from its attachment was brighter in colour and quite transparent. There appeared also to be a l9& On Grozvths in the Larynx. small wart on the left cord (Fig. 85, and Plate III. fig. n). The glottis, with the exception of the posterior sixth, was entirely Fig. 85. occluded. The larynx being very capacious, the growth large, and the patient steady, several large pieces were easily re- moved with common laryngeal forceps. On May 30th the growth on the right vocal cord was reduced to about a fourth of its former dimensions (Plate III. fig. 12), and it was now apparent that the small growth on the left side was attached to the under surface of the cord. Considerable difficulty was experienced in seizing this latter growth, but it was ultimately removed with antero-posterior laryngeal forceps. The remaining portions of the growth on the right vocal cord were subsequently eradicated, and early in November the voice Fig. 86. was perfectly restored. The portions removed were of very varied character and consistence. Some pieces were hard, others were of medium consistence, and one fragment, about the size of a large currant, was gelatinous and semi-transparent, 100 Consecutive Cases treated by the Author. 199 The following is the report of a microscopical examination, made by my brother, Mr. Stephen Mackenzie:—"Specimens submitted for examination exhibited various kinds of structure in different parts. In some portions the connective tissue predominated, whilst in others the fibrous arrangement was exceedingly regular and com- pact. In this part many of the fibres were elongated and fusiform, and the structure was almost that of a fasciculated sarcoma. One portion of it was almost gelatinous, and consisted of a nearly homogeneous intercellular substance and a few irregular caudate cells. In some parts there were an abundance of papillae. The growth much resembled, in the first portion described, the con- nective-tissue tumour of Vogel, while in the softer portions it approximated closely to a myxoma." (Fig. 86, and Plate I. fig. 4.) Case C—Papillomatous Growth on the Left Vocal Cord; Treatment by Evulsion; Cure. John F., aet. 51, a traveller, applied at" the Hospital for Diseases of the Throat, May 23rd, 1870, on account of hoarseness, from which he had suffered for five or six months. He attributed the dysphonia to frequent exposure to cold and variable weather. There was no other symptom of any kind. On examination with the laryngoscope, a large, round, slightly mammillated, growth, of the colour of the surrounding mucous membrane, was seen to occupy the anterior two-thirds of the left vocal cord. * On May 26th the growth was entirely removed with common forceps, in the presence of Mr. Julius Sankey and Mr. Pugin Thornton. The patient at once spoke clearly, and a fortnight later his voice was quite normal and the larynx free from any appearance of growth. On microscopic examination, the growth was found to be of papillary nature, the papillae being very abundant, but unusually short. The central portions of the tumour contained rather more connective tissue than is usual in papillomata. APPENDIX B. SHORT REPORTS OF A FEW CASES IN WHICH RADICAL TREATMENT WAS NOT ADOPTED. APPENDIX B. Case I.—Aphonia of tzvcuty years' duration from Grozvths on both Vocal Cords ; no Treatment. Elijah S., aet. 53, an inspector of police from Tunstall, con- sulted me, November 17th, 1863, on account of loss of voice, which had existed for twenty years. On laryngoscopic examination, the right vocal cord was seen to be entirely occupied by a flap-like growth, and on the left vocal cord there were also two small mammillary neoplasms. The patient attri- buted the aphonia to severe and repeated ulceration of the throat. He had travelled a long distance for an opinion, but was unable to remain in town for curative treatment. Case II.—Small Growth on the Posterior Wall of the Larynx ; no increase after interval of two years; no Radical Treatment re- commended. Mrs. B. was first seen by me at the London Hospital in November, 1863 ; she was at that time a patient under the care of Mr. Adams, on account of an abscess in the knee. She had entirely lost her voice for two years, and on examination with the laryngoscope I discovered a small irregular warty growth on the posterior wall of the larynx. It was attached rather to the right side of the median line. Palliative treatment, consisting of inhala- tions, was used with some benefit. I did not see the patient again till December 6 th, 1865. A drawing having been made on the first occasion of her consulting me, I was enabled to make an exact comparison of her larynx with the condition manifested two years previously. There was not the slightest alteration in the size of the growth, and therefore, as her voice was in some measure restored, and as there was no impairment of the respiration, I did not make any attempts at radical treatment. 27 204 On Grozvths in the Larynx. Case III.—Congenital (?) Aphonia; Excrescences in the Larynx; Death. The patient, a child, aged between 3 and 4 years, was brought to the Hospital for Diseases of the Throat early in 1864. She could not be examined with the laryngoscope, principally on account of the shape and position of the epiglottis. The case was a very interesting one, as the aphonia had been congenital, or had occurred immediately after birth. The mother had never known the child to utter a vocal sound. When it cried, tears came into its eyes, but it produced no sound. On introducing the finger into the larynx, during life, a hard round tumour was felt beneath the epiglottis. It seemed of cartilaginous or bony character, and was believed to be a growth connected with the thyroid cartilage. There appeared to be no doubt as to the nature of the case, and the patient was exhibited at the Medical Society of London, where several hospital physicians and surgeons carefully examined the larynx, and agreed as to the nature of the disease. The child subsequently died in an epileptic fit. Instead of a cartilaginous tumour, warty growths were discovered in the larynx. Some small warts, the largest of which was about the size of a tare, were found on the left vocal cord, and beneath the vocal cords on each side. The mucous membrane generally was of a warty or granular character. In this case, it will be seen that a correct diagnosis was arrived at, although one step in the investigation gave fallacious results. The digital examination indicated the presence of a hard growth at the base of the epiglottis, but, on post-mortem examination, soft warty excrescences were found on the left vocal cord. It became interesting to ascertain how this discrepancy in diagnosis had arisen, and on consideration, there could be no doubt that it had been caused by the hyoid bone being pressed down, when the finger was introduced into the mouth, and by its having been felt through the epiglottis. Though such cases are rare, and though the mistake could only happen before the cornua of the hyoid bone are developed,, this case is very instructive in a practical point of view, more especially as, previous to the publica- tion of this case, no attention has been called to this source of fallacy.—(Transactions of the Pathological Society, vol. xvi. pages 37 and 38.) Short Reports of some Untreated Cases. 205 Case IV.—Large Grozvth on the Right Vocal Cord; Treatment declined; Death by Suffocation. Mr. D. B., aet. 42, a merchant, consulted me on the 5th of July, 1865, by the advice of Dr. Scofield, of Birmingham, on account of hoarseness and occasional attacks of dyspnoea, which had existed for some months. On examination with the laryngoscope, I discovered an irregular, coarsely lobulated growth, springing from the centre of the right vocal cord, and obscuring more than four-fifths of the cavity of the glottis. I recommended the patient to remain in town and have the growth removed, but this he was unwilling to do ; I therefore wrote to Dr. Scofield, advising that, in the event of his symptoms becoming more urgent, tracheotomy should be performed. In this advice I was also supported by Mr. Furneaux Jordan, who saw. the patient on his return home. The patient, however, declined an operation, and he died suddenly, August ist, before the windpipe could be opened. Case V.—Out-growths on the Vocal Cords ; no Mechanical Treatment recommended. Mr. B., aet. 45, was brought to me, June 28th, 1866, by Dr. Hyde Salter, on account of hoarseness, which had been coming on gradu- ally for two years. This was the only symptom. On examination with the laryngoscope, a sessile nodule was seen on each vocal cord, the one on the right side being the larger (Fig. 87). Fig. 87. As these small projections appeared to be thoroughly incorporated in the subjacent tissues, I merely recommended the application of mineral astringents. (Medical Times and Gazette, June 13th, 1868.) 206 On Growths in the Larynx. Case VI.—Growth on the Left Vocal Cord ; no Treatment recommended. The Rev. J. H., aet. 73, living in Wales, was. brought to me by Mr. Richard James, of Notting Hill, Sept. 16th, 1866. The patient's voice had been impaired for between three and four years, but had been completely suppressed for two years. On laryngoscopic examination, a small nodal excrescence was seen on the centre of the left vocal cord. There was no distinct line of demarcation between the growth and the vocal cord, and as the patient was provided for by a pension, I did not think it desirable, at his advanced age, to recommend any operative pro- cedure. Case VII.—Growth on the Posterior Wall of Larynx; no Treatment. Miss I., aet. 49, first consulted me October 15th, 1866, on ac- count of hoarseness and shortness of breath. The former symp- tom had existed for between three and four years, but the dyspnoea, which was of a stridulous character, had only been occasionally present during the last seven months. On making a laryngoscopic examination, a pyramidal growth, about the size of a small kidney-bean, was seen projecting from the posterior wall of the larynx, upwards and forwards, into the cavity of the larynx, above the glottis. The patient came up from Devonshire, where she had been residing, on account of a supposed delicacy of the lungs ; but a careful stethoscopic examination failed to elicit any evidence of phthisis. Miss I. was very nervous, and refused to allow any attempt at removal. She subsequently placed herself under the care of my friend Surgeon-Major Wyatt, who has been able to give her some relief by the application of mineral astringents to the larynx. Case VIII.— Very small Grozvth on the inter-Arytcnoid Fold; no Mechanical Treatment recommended. Dr. A., a professor of languages, consulted me, October 18th, 1866, on account of hoarseness and cough. These symptoms had only existed for a few weeks, but he had long been subject to bronchitis in the winter. This gentleman was rather nervous, and Short Reports of some Untreated Cases. 207 it would have been very difficult to adopt operative procedure in his case, more especially as the growth was so very small. By the application of caustic solutions and stimulating inhalations, and with rest of the vocal organs, the symptoms gradually diminished, but there was no alteration in the size of the growth. Case IX.—Congenital Grozvth; Tracheotomy recommended but not permitted; Death by Asthenia ; Post-mortem Examination. Sophia W., aet. 2 years and 11 months, was sent to me by Dr. Sydney Ringer, July 9th, 1867. The patient was very weak and much emaciated, and her mother stated that from the time of her birth it was noticed that she never cried aloud, although she was able to make a harsh kind of crowing noise. As a baby, she always had great difficulty in sucking, and was obliged to stop very often to fetch her breath. The mother was unwilling to allow tracheotomy to be performed, and a few days after I first saw her, the child gradually sank from asthenia. On examining the larynx after death, the vocal cords were found to be covered by a fringe of warty growths. Case X.—Small Excrescence on the Right Vocal Cord; Mechanical Treatment not recommended. Mr. John T., aet. 61, residing at Bolton, consulted me, September 3rd, 1867, on account of general debility, loss of appetite, and hoarseness. He said that he had not felt well for some time, but that the aphonia had only existed for eight months, and he stated also that his voice was certainly not worse now than it had been three months previously, though it was always rendered more hoarse by cold and damp. He had no cough nor expectoration. Until the last year or so he had always enjoyed good health. On laryngoscopic examination, I discovered a small mammillated growth, the size of half a pea, springing from the centre of the right vocal cord, and preventing the cords from approximating closely in phonation. The symptoms in this case were not, in my opinion, sufficiently urgent to warrant immediate mechanical interference. I therefore recommended Mr. T. to spend the winter in a warm climate, and to return to me in the spring, when, if any important vocal symptoms had arisen, I proposed to remove it. This patient 208 On Growths in the Larynx. did not apply to me again ; but I heard from Dr. Livy, of Bolton, his usual medical attendant, that his voice continued in the same state. Case XL—Grozvths on each Vocal Cord; no Treatment. Mrs. B., aet. 52, consulted me in the spring of 1868, by the advice of Dr. Holman, of Hampstead. At that time she was suffering from enlargement of the veins of the larynx and posterior nares. Her complexion was pale, but the superficial capillaries were enormously enlarged and varicose. She constantly suffered from haemorrhage from the throat and posterior nares. I occasionally saw this lady, and her condition did not vary much; but in May, 1870, she came to me on account of hoarseness. I observed a small pea-like growth situated on the cartilaginous portion of each vocal cord. In view of the great disposition to haemorrhage, I felt some hesitation in operating on the growths, and I accordingly proposed a consulta- tion with an eminent surgeon. The patient, however, declined treatment. Case XII.—Sessile Growth on the Left Vocal Cord; Treatment declined. Captain G., aet. 42, consulted me on the 12th of March, 1869, on account of hoarseness, which had existed for some months. The patient had resided for many years in Australia, and had been much exposed to night air. His general health was not at all affected. On examination with the laryngoscope, I discovered a sessile, red, growth on the left cord,, which prevented approximation in phonation. I cautioned the patient that it was possible that more serious symptoms might in time arise ; but as at the time of his consulting me there was no other discomfort than the hoarseness, he objected to undergo any operative treatment. APPENDIX C. TABLE OF ONE HUNDRED CONSECUTIVE CASES TREATED BY THE AUTHOR. *#* Where the nature of the Growth was inferred from its naked-eye appearances, and no microscopic examination was made, the "Pathological Nature" is enclosed in parentheses. Where '' antero-posterior " forceps are stated to have been used, it means that this variety of the author's common laryngeal forceps has been employed. 28 210 On Growths in the Larynx. No. of Case. Date. Sex. Age. Occupation. I June, 1862 M. 40 Bookseller 2 April, 1863 F. 42 Housewife 3 April, 1863 M. 44 Carpenter... 1 4 April, 1863 F. 35 Mechanic's Wife. 5 May, 1863 M. 45 Gas-fitter ... 6 May, 1863 M. 40 Waiter 7 Aug. 1863 M. 41 Shoemaker 8 Jan. 24, 1864 M. 26 Sailor 9 Jan. 1864 F. 45 Lady IO April, 1864 F. 30 Milliner ... ii Oct. 1864 M. 4 Mechanic's child. 12 13 Nov. 1864 Jan. 1868 F. F. 6 28 Labourer's child. Fish-hawker 14 Jan. 1865 M. 46 Hawker ... Symptoms. Aphonia ... Aphonia ... Aphonia and Dys- pnoea. Aphonia Aphonia Dysphonia and fre- quent Cough. Dysphonia Dysphonia and Dysphagia. Aphonia and great Dyspnoea. Aphonia ... Aphonia, stridulous Breathing, and attacks of Suffo- cation. Aphonia ... Constant tickling in Larynx (nei- ther Aphonia nor Dysphonia). Aphonia ... Situation. Epiglottis Right Ary-epiglottic Fold and Ventri- cular Band. Almost the entire lining membrane of Larynx. Both Vocal Cords, and below Vocal Cords. Left Vocal Cord Both Vocal Cords Anterior Commissure of Vocal Cords. Epiglottis and Right Ventricular Band. Right Vocal Cord Both Vocal Cords Just above Anterior Commissure of Vocal Cords, and beneath Vocal Cords. Both Vocal Cords ... Posterior part of right Vocal Cord. Right Ventricular Band and both Vocal Cords. Pathological Nature. (Papilloma) (Papilloma) Papilloma... (Papilloma) Papilloma... (Papilloma) Fibroma ... Benign Epi- thelial Growth. Papilloma... (Papilloma) Papilloma... Papilloma... (Papilloma) Benign Epi- thelial Growth. Table of 100 Consecutive Cases treated by the Author. 21 I Destruction with caustic solu- tions. Destruction with caustic solu tions. Evulsion with tube-forceps, and application of escharotics. Evulsion with tube-forceps ... Evulsion with tube-forceps ... Evulsion with tube-forceps, and incision of base. Evulsion with common laryn- geal torceps. Evulsion with common laryn- geal forceps. Partial evulsion with tube-for- ceps. Evulsion with common laryn- geal forceps. Evulsion with tube-forceps ... Evulsion with tube-forceps Evulsion with tube-forceps Partial evulsion with common laryngeal forceps. References and Remarks. Great improve- ment. Improvement Cure Cure Cure Cure Cure Cure Great improve- ment. Cure Cure Cure Cure Improvement Seen by Professor Czermak. (The Use of the Laryngoscope, second edition, p. 86.) Voice still hoarse. Slight diminution in size of Growth. Patient was obliged to return home sud- denly. She left with a distinctly phonetic but rather harsh voice. ( The Use of the | Laryngoscope, second edition, p. 87.) Seen by Drs. Czermak, Frodsham, and others. (The Use of the Laryngoscope, second edition, p. 121.) Recurrence on both ventricular bands, March 7, 1870. Second series of four operations with com- mon laryngeal forceps. Cure. Sent by Mr. Brown, of Finsbury. (The Use of the Laryngoscope, second edition, p. 123.) Seen by Drs. Czermak, Wahltuch, and others. (The Use of the Laryngoscope, second edition, p. 125.) Seen by Dr. George Johnson, &c. (The Use of the Laryngoscope, second edition p. 126.) Dr. GeorgeJohnsonandMr. Francis Mason present at operation. ( The Use of the Laryngoscope, second edition, p. 128.) Seen by Mr. George Evans. Fresh Growth (Feb. 1866) beneath anterior Commissure of Vocal Cords. Removal with tube- forceps, and Cure. Seen on second occa- sion by Drs. Tatham and Thurgar. Breathing became more natural. Voice remained slightly hoarse. Portions re- moved were examined by Dr. Andrew Clark. Sent by Mr. Parsons, of Bridgewater. ( The Use of the Laryngoscope, second edi- tion, p. 130.) (Transactions of Pathological Society, vol. xvi. p. 38.) Ibid., p. 39. Seen by Dr. Mill Frodsham. Patient discontinued attendance. Micro- scopical examination by Dr. Andrew Clark. 212 On Growths in the L.arynx. No. of Case. '5 16 17 19 24 25 26 27 28 29 30 Tan. 1865 May 10, 1865 Jtfne, i86 . 1867 ! 36 - Jan. ; M. I 17, 1867 37 Feb. M. 1867 38 Mar. 1867 39 Mar. 1867 40 Mar. 1867 4i Mar. 1867 42 May, 1867 43 May, 1867 44 June, 1867 45 June 13, 1867 46 July 3, 1867 Age. Occupation. Symptoms. Situation. m. : 52 53 Vocalist ... Laundress... Vocalist ... Lady Railway Porter. Gardener .. Overseer in coal-mine. Lady Vocalist .. Labourer .. Servant .. Missionary Housewife Dysphonia and fre- I Left Vocal Cord quent Cough. Pathological Nature. (Papilloma) Dyspnoea .. Dysphonia Left Capitulum San- (Papilloma) torini. 1 Right Vocal Cord ... i (Papilloma) Aphonia ... ... Right Vocal Cord ... 41 j Housewife 30 Watch- maker's wife. 31 Lady Dysphonia Aphonia and se- rious Dyspnoea. Aphonia ... Dysphonia Dysphonia Complete Aphonia Slight Dysphonia... Aphonia ... Aphonia, Dyspnoea, and Cough. Dysphonia, slight Cough, Dyspnoea, and occasional feeling of Suffo- cation. Aphonia and great Dyspnoea. Aphonia Right Vocal Cord ... Right Vocal Cord Right Vocal Cord and under surface of Epiglottis. Posterior wall of Larynx. Left Vocal Cord Symmetrical Growths on both Vocal C ords. Under surface of Epi- glottis. Right Vocal Cord ... Posterior Wall of Larynx. Right Ventricular Band. Both Vocal Cords ... Whole lining mem- brane of Larynx. (Papilloma) (Papilloma) Small (fi- brous) Growths. intimately associated with subja- cent parts. Papilloma... (Papilloma) Fibroma ... (Papilloma) Fibro-cellu- lar Growth. (Fibroma)... Papilloma. Papilloma. (Papilloma) (Papilloma) Table of 100 Consecutive Cases treated by the Author. 215 Treatment. Result. References and Remarks. Incision of base of Growth ... Evulsion with tube-forceps ... Evulsion with tube-forceps ... Division of base of Growth ... Evulsion with tube- and antero- posterior forceps. Attempted evulsion with com mon laryngeal forceps and abscission. Tracheotomy. Evulsion of all but a minute piece with tube-forceps. Incomplete destruction by gal- vanic cautery. Evulsion with tube-forceps ... Evulsion with antero-posterior laryngeal forceps. Destruction by galvanic cau- tery. Destruction by galvanic cau- tery. Evulsion with tube-forceps ... Evulsion with tube-forceps Partial evulsion with tube-for- ceps. Evulsion with tube-foreeps Cure Cure Cure Cure Cure Improvement in respiration. Cure Negative Cure- Great improve- ment. Cure Cure ...... Cure Cure Improvement Cure The Growth atrophied after incision of base. Operated on in presence of Dr. Taylor, Dr. Merryweather, and others. Patient seen by Mr. Evans. Case seen in consultation with Mr. Evans. Case seen before and after treatment by Drs. Hun and Lockwood, of New York. (Medical Times and Gazette, June 13, 1868.) Case seen during treatment by Dr. Pogojeff, of Odessa, and Mr. Du Pasquier. Tracheotomy performed by Mr. Evans. Difficulty of breathing relieved, but Aphonia remained. Canula always worn. Sent by Dr. Griffiths, of Swansea. Recur- rence May 25, 1868, in same situations. Removal; no further recurrence. (Medi- cal Times and Gazette, June 13, 1864.) Case sent by Dr. Addington Symonds. Case sent by Dr. Marion Sims. Patient satisfied with phonetic but hoarse voice. Dr. McCall Anderson present at operation. Case seen before treatment by Drs. Atkin- son and Macaldin. Inflammation of the Larynx followed. Mr. Lennox Browne present at the operation. Case seen frequently by Dr. Pelechin, of St. Petersburg. May, 1868. Larynx remained quite healthy. Tumour examined microscopically by Dr. Andrew Clark. Patient was advanced in pregnancy when treatment commenced, and was unable to remain in Hospital on that account. Tra- cheotomy was subsequently performed by Mr. De Berdt Hovell, of Clapton. Case known to Dr. Money, of Brighton. Recurrence June 27, 1870. Second series of operations with tube-forceps, and recovery of voice. 2l6 On GrozvtJis in the Larynx. No. | of ! Date. Case. 1 Sex. Age. Occupation. Symptoms. Situation. Pathological Nature. ! 47 1 July | M. 45 Shoemaker Aphonia and Cough Both Vocal Cords ... (Papilloma) 1867 48 ' July, M. 30 Furniture- Aphonia ... ... ! Under surface of Epi- Fibro - cellu- 1867 dealer. glottis. lar Growth. 49 j July, F. 53 Bible-reader Aphonia, Dys- Under surface of Epi- Fasciculated 1867 pnoea, and severe glottis and anterior Sarcoma. Dysphagia. Commissure of Vo-cal Cords. 50 Sept. M. 10, 1867 64 Merchant ... Aphonia ... Right Vocal Cord ... (Papilloma) 51 Oct. : M. 1867 55 Dispenser ... Aphonia ... Right Vocal Cord ... (Papilloma) 52 Oct. F. 65 Lady Aphonia and Dys- Right Vocal Cord ... Fibro-cellu- 1867 pnoea. lar Growths ! 53 Nov. 1867 M. 26 Butcher ... Aphonia ... Both Vocal Cords ... (Papilloma) Great gene-ral Hyper- emia. 54 Dec. 12, M. 43 Farmer Aphonia ... Right Vocal Cord ... Benign Epi-thelial 1867 Growth. 55 Dec. M. 13 ■ Washer- Dysphonia and dys- Left Vocal Cord (Papilloma) 16, woman s pnoea. 1867 son. 56 Dec. M. 34 Sugar-baker Dysphagia ; con- Under-surface of left Fibroma ... 1867 stantdesire to clear throat. Aphonia and Short- side of Epiglottis. 57 Dec !M. 17 Engine-fitter Left Vocal Cord and (Papilloma) 1867 ness of Breath, but no Dyspnoea. under-surface of Epi-glottis. 58 Jan. 7, 1868 M. 10 Artisan's child. Aphonia ... Right Ventricular Band. Benign Epi-thelial Growth. 59 Jan. 13, 1868 M. 42 Carman ... Aphonia ... Right Vocal Cord and Right Ventricle. Fasciculated Sarcoma. 60 Feb. 6, 1868 F. 23 Servant Dyspnoea ... Right Vocal Cord ... Papilloma... 61 Feb. 8, 1868 F. 31 Lady Aphonia ... Right Vocal Cord ... (Papilloma) 62 Feb. 1868 F. 57 Fish-hawker Dysphonia and Cough. Right Vocal Cord ... (Papilloma) Table of ioo Consecutive Cases treated by the Author. 17 Treatment. Evulsion with common laryn- Cure geal forceps and tube-forceps. Evulsion with tube-forceps ... Cure Partial destruction by electric Considerable im- cautery, and subsequent evul- provement. sion with cutting forceps. Evulsion with common laryn- i Cure geal forceps. Result. References and Remarks Partial evulsion. Crushing with strong forceps. Evulsion with common laryn- geal forceps. Partial evulsion with antero- posterior forceps. Evulsion with tube-forceps Evulsion and . crushing with common antero-posterior forceps. Evulsion with common laryn- geal forceps. Evulsion with tube- and com- mon laryngeal forceps. Evulsion of fragments with tube-forceps. Cure Cure Improvement Destruction with caustic and Cure astringent solutions. Cure Evulsion with common laryn- Cure geal forceps. Evulsion of a portion with Cure tube- and common forceps and Stoerk's ecraseur. Evulsion with tube-forceps ... Cure Great improve- ment. Still un- der treatment. Cure Cure Negative Case seen during treatment by Surgeon- Major Trestrail and the Rev. David Bell, M.D. Surgeon-Major Trestrail present at opera- tion. Dyspnoea and Dysphagia quite relieved ; voice sufficiently restored to enable her to resume her employment. Microscopical examination by Mr. Stephen Mackenzie. Operation performed in presence of Mr. Lennox Browne. Case sent by Mr. Ince. Surgeon-Major Trestrail and others present. This Growth, the size of a cherry, was re- moved completely in one operation. (Transactions of Pathological Society, vol. xix. p. 60.) Patient discontinued attendance after two pieces of Growth had been removed in the presence of Surgeon-Major Trestrail. Patient frequently seen by Surgeon-Major Trestrail and others. Drs. Welch and Pelechin present. Case seen by Dr. Alexander Fox. Sent by Dr. Johnston, of Barnstaple. Seen again in March, 1869, when there was no return of Growth. (Medical Times and Gazette, June 13, 1868.) Dr. Alexander Hewan and others present during treatment. Constant recurrence, the tumour appearing to grow afresh between each visit. Pa- tient seen and fragment examined micro- scopically by Dr. Fenwick and Mr. Stephen Mackenzie. Operated on in presence of Surgeon-Major Trestrail and Dr. Wilkie. Sent by Mr. Harston, of Islington. Fresh Growth in consequence of not all having been removed on the first occasion. Com- plete recovery ultimately. (Medical Times and Gazette, June 13, 1868.) Patient did not apply after second visit. 29 218 On Growths in the Larynx. No. of Date. Sex. Age. Occupation. Case 63 Feb. 1868 M. IO Gentleman's son. 64 April 21, 1868 F. 66 Spinster lady. 65 May M. 34 Twine- 4, 1 spinner. 1868 66 June 4, 1868 M. 3° Waiter 67 June, 1868 M. 36 Woolpacker 68 July 3, 1868 M. 8 Wine-mer-chant's son. Symptoms. 69 July F. 12 7, 1868 ; 70 July 9, 1868 M. 48 7« July 13, 1868 M. 27 72 Aug. 1868 M. 47 73 Oct. 1868 F. 18 74 Oct. 1868 M. 4i 75 Nov. 1868 M. 15 76 Dec. 1868 F. 3i Mechanic's child. Woolpacker Telegraphist Hawker ... Artist Labourer Aphonia and Dys- pnoea. Aphonia and severe Dyspnoea. Aphonia .. Dysphonia Aphonia .. Almost complete Aphonia. Dysphonia and se- vere Dyspnoea. Aphonia ... Aphonia, slight Dyspnoea, hack- ing Cough. Dysphonia Situation. Anterior Commissure Papilloma. of Vocal Cords. Pathological Nature. Dysphonia Dyspnoea. and Both Vocal Cords, nearly filling the Glottis. Left Ventricular Band Both Vocal Cords ... Two Growths on right Vocal Cord. Right Vocal Cord ... Both Vocal Cords ... Right Vocal Cord ... On and beneath both Vocal Cords. Right Vocal Cord ... Left Vocal Cord, occupying anterior two-thirds of Glottis. Page Housewife Dysphonia and Dyspnoea. Dysphonia •Aphonia (Papilloma) Papilloma .. (Papilloma) (Papilloma) Papilloma... (Papilloma) (Papilloma) (Papilloma) (Papilloma) (Fibro- cellular Growth.) Whole length of left Fibro-epi- Vocal Cord. thelial Growth. Left Vocal Cord \bove and below An- terior Commissure and Right Vocal I Cord. (Papilloma) (Papilloma) Table of i oo Consecutive Cases treated by the A uthor. 219 Treatment. Evulsion with tube- and com- mon forceps. Evulsion of a portion with common forceps ; subse- quently Tracheotomy and Thyrotomy. Evulsion with common laryn- ' Cure geal forceps. Result. Cure Cure Evulsion with common laryn- geal forceps. Partial evulsion with tube-for- ceps. Evulsion with tube-forceps, and destruction with caustic solutions. Tracheotomy and Thyrotomy Evulsion with antero-posterior forceps. Evulsion with tube and common laryngeal forceps. Evulsion with antero-posterior forceps. Evulsion with tube-forceps ... Cure Improvement Cure Improvement Cure Cure Cure Cure Evulsion of a portion with Cure common antero-posterior for- ceps. Tracheotomy. Excision with cutting foreeps. Evulsion with tube-forceps Evulsion with tube-forceps Cure Curt The Growth, | of an inch long and -\ an inch broad, was of not more than six months' standing. Patient sent by Mr. Graves, of Gloucester. (Medical Times and Gazette, June 13, 1868.) Tracheotomy and Thyrotomy performed by Mr. Couper. Complete restoration of voice. Recurrence 2^ years later. Case seen by Dr. Carlill, Dr. Sykes, and Dr. Henry Roberts (Manchester). Dr. Simpson, of Manchester, and Mr. Bal- manno Squire present. Patient recovered and retained phonetic but gruff voice. Vocal Cords remained rough. Patient sent to me by Mr. Sankey, of Maidstone. Fresh Growth two years later on posterior Wall, and on left Vocal Cord. Repetition of treatment and recovery of good voice. Operation performed by Mr. Evans. Dyspnoea cured, but the aphonia un- relieved. Drs. Jagielski, O'Keefe, and Chatterton present. The patient came from Malta, and was operated on, on one occasion, in the presence of Dr. Gray, of Oxford. Case first seen by Mr. Lennox Browne. Paralysis of abductor of left Vocal Cord coming on two months after evulsion of Growth, Tracheotomy became necessary. Operation by Mr. Evans. Patient died eighteen months later, and at autopsy there was no vestige of the Growth. Patient ceased attendance, content with improvement. Increase of remnant, and Tracheotomy by Mr. Thornton, October, 1869. Subsequent evulsion of all the Growth with cutting forceps, and removal of tube. Present, Dr. Greenaway, Dr. Gourlay, and others. Recurrence in same position, September, 1869. Second series of operations in presence of Dr. .Stage, of Copenhagen, Mr. James Keene, &c. Cure. Case sent by Dr. Baumler, by whom the patient was examined with laryngoscope before and after treatment. 220 On Growths in the Larynx. No. of Case. Date. Sex. 77 78 79 80 81 82 85 86 87 88 89 Jan. 1869 Feb. 186c Mar. April 21, 1869 May 27, May May, 1869 June, i860 June 28, 1869 June, 1869 Sept. 18, Oct. 12, 186 Dec. 1869 Age. Occupation. Vocalist Publican Stonemason Merchant Charwoman Servant Symptoms. Cough, slight Dys- phonia inordinary voice, total loss of singing voice. Aphonia and Dys- pnoea. Dysphonia Dyspnoea. and Situation. F. 21 M. 22 M. 43 M. 47 M. 5i M. 35 51 Housewife Servant Farrier Farmer Silversmith Officer in H. M. S. Captain in H.M. Ma- rines. Hoarseness and troublesome Cough. Stridulous Breath- ing and Dyspnoea. Never able to sound her voice; great t Dyspnoea one year. Dysphonia and Dysphagia. Great Dyspnoea, at- tacks of strangula- tion, occasional Aphonia. Dysphagia and slight hoarseness. Complete Aphonia; severe Dyspnoea. Severe paroxysmal Cough, Dyspho- nia, and Dyspnoea. Cough and Dyspha- gia. Voice nor- mal. Uneasy tickling sensation in the throat. Posterior Wall of Larynx. Left Vocal Cord Beneath Anterior Commissure of Vocal Cords. Both Vocal Cords ... Posterior Wall of Larynx beneath the Vocal Cords. Both Vocal Cords .. Right Vocal Cord and under surface of Epiglottis. Both Vocal Cords ... Large globular Growth, occupying right side of Epi- glottis. Just below Anterior Commissure. Right Vocal Cord ... Under Surface of Epiglottis. Hyoid Fossa Pathological Nature. Papilloma.. Fibroma ... Adenoma ... (Papilloma) (Papilloma) Papilloma... Papilloma... Papilloma... (Cystic Growth.) (Papilloma) Epitheli- oma. Adenoma Vascular tu- mour. Table of 100 Consecutive Cases treated by the Author. 221 Treatment. Evulsion with tube-forceps Evulsion with ordinary laryn- geal and tube-forceps. Evulsion with tube and ordi- nary antero-posterior forceps, and Stoerk's ecraseur. . Evulsion with tube-forceps ... Laryngotomy. Growths after- wards removed through ca- nula opening in crico-thyroid space. Evulsion with tube-forceps and cutting forceps. Evulsion of Growth under Epiglottis, and portion of that on Vocal Cord, with tube- forceps. Evulsion with tube-forceps, Stoerk's ecraseur, and com- mon laryngeal forceps. Result. Evulsion of all but a minute piece with tube-forceps and Stoerk's ecraseur. Tracheotomy and Thyrotomy Tracheotomy. Subsequent re- moval of Growth through upper orifice of larynx, with guarded wheel-ecraseur. Evulsion with tube-forceps and excision with cutting forceps, Cure Cure Cure Cure Cure Cure Improvement Cure Incision, evacuation of con- Cure tents, and application of solid caustic. Great improve- ment. Death 8 months after operation. Improvement ; still under ob- servation. References and Remarks. Cure In September, 1869, Larynx remained healthy. Portion of Growth examined by Dr. Fenwick. Seen with Dr. Weber, February 12th, 1869. Seen by the Rev. Dr. Bell, M. D. Treated, in conjunction with Dr. Simpson, of Manchester. Growth not seen, on account of paralysis of abductors of the Vocal Cords, till ten days after operation. Voice and breathing now normal. Tube has long been re- moved. Seen by Dr. Boddaert, of Ghent, and Mr. Wordsworth. Case briefly reported in Lancet, June 5, 1869, p. 779. The Larynx in this case is not larger than that of a child aged eight years. Patient discontinued attendance. Growth examined by Dr. Fenwick. Patient seen York. by Dr. Elsberg, of New At the expiration of a month there was not even a scar. Case seen by Dr. Gore Ring. Sent by Dr. Lewis, of Basingstoke. Operation performed by Mr. Wordsworth. Post-mortem examination showed that the whole larynx and tracheal opening, as well as the skin surrounding the tube, were occupied by an enormous mass of warty Growths, all developed since the operation. Tracheotomy by Mr. James Adams. Sub- sequent removal of Growth in presence of Mr. Clover. (Transactions of Patho- logical Society, vol. xxi. p. 51.) Sent by Dr. Smyly, of Dublin. 222 On Grozvths in the Larynx. No. of Date Sex. Age. Occupation. Symptoms. Situation. Pathological Nature. \ Case. M. 44 90 Jan. Labourer Dysphonia; sense Above and below Papilloma... 20, of oppression about Anterior Commis- 1870 throat. sure. 91 Jan. 1870 M. 47 Wine-bottler Aphonia ... Both Vocal Cords (Papilloma) 92 Felj. F. 48 Haberdasher Aphonia 24 years... Left Vocal Cord, and Benign 3, beneath it. Epithelial 1870 Growth. 93 Mar. 3, 1870 M. 30 Engine-driver. Dysphonia Left Vocal Cord (Papilloma) 94 Mar. 7, 1870 F. 35 Gilder's wife Aphonia ... Left Vocal Cord (Papilloma) 95 Mar. F. 43 Coachman's Aphonia 23 years... Right Ventricular Fasciculated 9, wife. Band. Sarcoma. 1870 9^ Mar. 14, 1870 F. 27 Machinist... Aphonia ... Posterior Wall Larynx. of Papilloma... 97 Mar. 21, 1870 F. 29 Butcher's wife. Great pain and effort in speaking, and Dysphonia. Posterior Wall Larynx. of Fibroma ... 98 May M. 21 z2 Lighterman's Aphonia from birth; The entire cavity of Benign 10, child. great Dyspnoea. Larynx. Epithelial 1870 Growth. 99 May, 1870 M. 21 Gentleman Dysphonia Both Vocal Cords Fibro-cellular Growth and Myxo-ma. 100 May 23, 1870 M. 51 Traveller ... Dysphonia Left Vocal Cord 1 (Papilloma) Table of 100 Consecutive Cases treated by the A uthor. 223 Treatment. Evulsion with tube-forceps and common laryngeal forceps. Evulsion with common antero- posterior forceps. Evulsion with antero-posterior forceps. Evulsion with antero-posterior forceps. Evulsion with antero-posterior forceps. Evulsion with common laryn- geal forceps. Evulsion with tube-forceps ... Evulsion with common laryn- geal forceps. Tracheotomy ... Evulsion with common and antero-posterior forceps. Evulsion with common forceps Cure Cure Cure Cure Cure Cure Cure Cure Death Cure Cure References and Remarks. Case operated on in the presence of Dr. Thorowgood, Mr. H. A. Reeves, and others. Case seen by Surgeon-Major Wyatt, Dr. Farquhar, and others. Operation in presence of Dr. Haden. Growth removed in one operation, in presence of Dr. Henry Hubbard and Mr. Keene. Growth removed in one operation, in pre- sence of Dr. Stage and Mr. Keene. Case known to Dr. Carre, of Blackheath. Pieces removed in presence of Mr. Keene and Dr. Collum. Case seen by Dr. Bowditch, of Boston, U.S.A., and Dr. Webb, of Cincinnati. On post-mortem examination, the Larynx was found to be blocked up by Growths. Case known to Dr. Thomson, of Devon- port. Growth entirely removed, on first attempt, in presence of Mr. Sankey and Mr. Pugin Thornton. APPENDIX D. TABLE OF ALL PUBLISHED CASES TREATED BY OTHER PRACTITIONERS SINCE THE INVENTION OF THE LARYNGOSCOPE. ----o---- *** From this Table all Cases of malignant disease, as well as all Cases ofilfalse excrescences," have been carefully excluded. Notwithstanding the great pains which have been taken to search every publication accessible in this country, it is quite possible that a few Cases may have been accidentally overlooked. The Author is also aware that a large number of other similar Cases have been treated, though they have not yet been placed on record. 30 226 Table of all published Cases treated by other No. of Date. Sex. Age. Occupation. Symptoms. Situation. Pathological Nature. Case. I July 20, i860 M. 33 Merchant.. Dysphonia, Dys-pnoea, and Cough. Anterior portion of left Vocal Cord. Benign Epi-thelial Growth. 2 i860 F. 15 Aphonia and Dys-pnoea. One large Growth at anterior Commis-sure. A smaller one below Anterior Commissure. Soft and gra-nular Growth. 3 i860 F. 20 Aphonia ... Left Vocal Cord and right Ventricle. Numerous Warty Growths. 4 i860 M. 56 Hoarseness, Cough on deglutition. Sensation of fo-reign body in Throat. Right Ventricle Greyish -whitt Polypoid Growth. 5 Aug. i860 F. 29 Lady Aphonia and Dys-pnoea. Right Vocal Cord ... Not stated 6 Oct. i860 M. 24 Lapidary ... Aphonia, Dyspnoea, and Pain. Both Vocal Cords and Ventricular Bands. Not stated 7 Oct. 27, 1862 F. 22 Aphonia and Cough Right Vocal Cord ... Not stated 8 i860 M. 43 Merchant... Hoarseness, per-sistent Cough, and burning Sensation in Throat. Anterior Commissure Pedunculated Mucous Polypus. 9 i860 M. 40 Merchant ... Sensation of pres-sure and burning in Throat. Anterior wall of Larynx. Pedunculated Polypus. IO Nov. 2, i860 F. 20 Lady Varying Aphonia... Two Growths on left Vocal Cord. Not stated u i860 M. 43 Tailor Aphonia ... Whole length of both Vocal Cords. Papilloma... 12 Dec. i860 M. 32 Merchant ... Hoarseness and Cough. Posterior wall of Larynx. 13 i860 F. 3i Loud barking Cough, after Croup. Posterior wall of Larynx. Not stated H i860 M. 7 Aphonia, Dyspnoea, Stridor, and Cough. Right Ventricle Mucous Po-lypus. 15 1861 M. 48 Printer Not mentioned ... Anterior Commissure and right Vocal Cord. Papilloma... 16 1861 F. Not stated The entire lining mem-brane of the Larynx. Cellular-Sar-coma and Papilloma. Practitioners since the Invention of the Laryngoscope. 227 Treatment. Excision with scissors and forceps. Evulsion of portion with forceps. Subsequent cau- terization with nitrate ol silver. Cauterization and evulsion with forceps. Cauterization Destruction with caustic solutions. Destruction wrth caustic solutions. Destruction with caustic solutions. Destruction with caustic solutions. Cauterization for a fort- night. Sudden disap- pearance of tumour. Destruction with caustic solutions. Partial evulsion with for- ceps. Cauterization One application, under chloroform, of solution of nitrate of silver. Two successive cauteriza- tions with solid nitrate of silver. Evulsion with forceps ... Tracheotomy. Division of Thyroid Cartilage, ex- cision of Growth and of right Vocal Cord with knife. Result. Cure ... Cure ... Improvement Cure ... Cure ... Cure ... Cure ... Cure ... Cure ... Cure ... Negative Negative Cure ... Cure ... Temporary benefit. Improvement Operator. Dr. Lewin Idem Idem Idem Sir Duncan Gibb. Idem Idem Lewin Idem Gibb Lewin Idem Idem Idem Dr. Fauvel Dr. Rauch- fuss. Reference and Remarks. Deutsche Klinik, 1862, p. 202. Growth returned in nine months, but patient refused further treat- ment. Ibid., 1862, p. 202. Ibid., p. 203. Ibid., 1862, p. 243. This Growth was believed to originate from irritation of a fish-bone in the Larynx. Diseases of the Throat, &c., second edition, p. 143. Ibid., p. 142. Ibid., p. 144. Deutsche Klinik, 1862, p. 244. Ibid., p. 245. Diseases of the Throat, &c, second edition, p. 145. Deutsche Klinik, 1862, p. 258. Ibid., p. 259. Ibid., p. 245. It is scarcely possible that this could have been a case of true Growth. Ibid., p. 257. Du Laryngoscope au point de vice pratique. Paris, 1861. St. Petersburg mediz. Zeitsch., 1862, vol. vi. p. 44. Death two years later from Gangrene of Lungs. On Autopsy, communication be- tween the middle of trachea and oesophagus. Right bronchus contained a chicken-bone. 228 Table of all published Cases treated by other No. of Date. Case. Sex. Age Occupation. Symptoms. Situation. Pathological Nature. 17 1861 Not stated Not stated...... Not stated l8 1861 M. 25 Not stated Anterior Wall of Larynx. 19 July 20, 1861 M. 48 Librarian ... Aphonia and Cough Below the anterior Commissure of Vocal Cords. Fibroma ... 20 1861 M. 26 Gardener ... Hoarseness, Cough, and Dyspnoea. Right Ventricular Band. Benign (?) Epithelial Growth. 21 1861 M. 14 Labourer ... Aphonia and Dys-pnoea. Above Vocal Cords Not stated 22 Jan. 14, 1862 M. 62 Merchant ... Aphonia, occurring suddenly. Both Vocal Cords, both Ventricular Bands, and Epi-glottis. Benign (?) Epithe-lioma. 23 1862 M. 29 Schoolmaster Dysphonia Right Vocal Cord and posterior Wall of Larynx. Papilloma... 24 1862 M. 60 Apothecary Hoarseness Below anterior Com-missure, and on left Vocal Cord. Polypus ... 25 1862 M. 45 Gentleman Hoarseness Right Vocal Cord ... Papilloma... 26 April 19, 1862 M. 3i Fireman ... Aphonia ... Posterior Wall of Larynx. Not stated 27 Oct. 17, 1862 M. 27 Left Vocal Cord ... Mucous Polypus. 28 1862 F. 20 Aphonia ... Anterior Commis-sure of Vocal Cords and Ventricular Bands. Not stated 29 1862 F. 39 Lady Aphonia, Cough, and Oppression. Two Growths below Vocal Cords. Polypus ... 3° Nov. 1862 M. 37 Gentleman Aphonia ... Two Growths on left Vocal Cord. Fibro-Epi-thelial 31 Dec. 10, 1862 M. 42 Gentleman Hoarseness Anterior Commissure Growth. Ditto 32 Dec. 23. 1862 M. 47 Captain in Merchant Service. Hoarseness Between Vocal Cords and on left Vocal Cord. Not stated 33 Dec. 1862 M. 37 Clergyman Hoarseness and temporary Apho-nia. Left Vocal Cord Fibroma ... Practitioners since the Invention of the Laryngoscope. 229 Treatment. Destruction by insufflation of powdered nitrate of silver. Tracheotomy, March 26, 1861 ; Thyrotomy, Aug. 13, 1862. Excision with scissors ... Evulsion with curved for- ceps. Evulsion with ecraseur ... Evulsion with forceps, and subsequent cauteri- zation. Result. Operator. Cure ... Improvement Cure ... Improvement; recurrence. Great improve- ment. Improvement Excision with knife ; ap- plication of nitrate of silver and galvano-cau- tery. One excised with knife; the other destroyed by nitrate of silver and galvano-cautery. Excision with galvanic- cautery wire and laryn- geal forceps. Destruction with nitrate of silver and chromic acid. Evulsion with curved for- ceps, and subsequent cauterization. Destruction with galvanic- cautery. Excision with guillotine, in two sittings. Evulsion with ecraseur ... Evulsion with ecraseur, under chloroform. Evulsion with ecraseur ... Excision with double- edged knife. Improvement Cure Great improve- ment. Improvement Great improve- ment. Improvement Cure ... Cure ... Cure ... Cure ... Cure ... Dr. Knauf Dr. Gurdon Buck. Prof. Bruns Messrs. Bra- cey and Bolton. Dr. Walker Prof. Czer- mak. Reference and Remarks. Schmidt's Jahrbiicher, 1862, No. 6, p. 114. The tumour shrank, and was subsequently expelled. New York Medical Journal, May, 1865. Tracheotomy was performed for supposed abscess. Die Laryngoskopie. Tubingen, 1865, P- 57- Dr. Russell, On Laryngeal Diseases, &=c, p. 16. 1864. Reprinted from Brit. Med. Journal. Lancet, Nov. 9, 1861. Die KehlkopfSpiegel, 1863, p. 117. Dr. Voltolini I Die Anwendung der Galvanocaustic, &*c. Wien, 1867, p. 51. Case 4. Idem ... Lbid., p. 58. Case 6. Idem ... Ibid., p. 56. Case 7. Dr. Louis! Treatment of Morbid Growths within Elsberg. \ the Larynx. Philadelphia, 1866. j Case 2. Dr. Weiss .. ] St. Petersburg mediz. Zeits., 1864, p. 10. Growth recurred in 1863 and in March, 1864 ; was again completely removed by same means as before. Voltolini ... Die Anwendung der Galvanocaustic, p. 52. Case 5. Dr. Charles Ozanam. Gibb Idem Idem Bruns Compte rendu de PAcademie des Sciences, June 16, 1863. Diseases of the Throat, &>c., second edition, p. 147. Ibid., p. 149. Ibid., p. 150. Die Laryngoskopie, &c. Tubingen, 1865, p. 270. 230 Table of all published Cases treated by other No. of Date. Sex. Age. Occupation. Symptoms. Situation. Pathological Nature. Case. 1 34 Nov. M. 45 Anterior half of both Cauliflower 28, Vocal Cords. Polypi. 1862 35 1863 M. 31 Priest Hoarseness Anterior Commissure Not stated 36 Jan. 1863 M. 22 Railway offi-cial. Hoarseness and slight Haemopty-sis. Right Vocal Cord ... Fibro-cellular Polypus. 37 Feb. 1863 M. 15 Aphonia and At-tacks of Suffoca-tion. Whole inner surface of Larynx. Papilloma... 38 Feb. 1863 M. 51 Hoarseness Posterior Wall of Larynx. Not stated 39 Mar. 1863 M. 40 Aphonia ... Epiglottis, right Vocal Cord, and left Ary-tenoid Cartilage. Papilloma... 40 1863 F. Epiglottis Fibroma (as large as a walnut). 41 Mar. 26, 1863 F. 39 Internal surface of left Ary-epiglottic Fold. Fibroma Polypus as large as a filbert. 42 Mar. 29, 1863 F. Vocal Cord ... Nodulated Tumour. 43 Mar. 1863 M. Hoarseness and Attacks of Suffo-cation. Several Growths filling the Larynx. Polypi 44 1863 M. Vocal Cord ... Firm lobu-lated Poly-pus. 45 Mar. 29, 1863 F. 25 Lady Aphonia ... Posterior Wall of Larynx. Not stated 46 Mar. 1863 F. 16 Aphonia and Dys-pnoea. Posterior Wall of Larynx. Not stated 47 1863 M. Boy Aphonia ... Left Vocal Cord Two Polypi 48 May, 1863 M. 28 Warehouse-man. Almost complete Aphonia. Left Vocal Cord and left Ventricular Band. Fibroma .. 49 1863 F. Lady Speaking voice changed ; singing voice lost. Right Vocal Cord ... Polypus ... 5° 1863 M. Mid. Age Coal-mer-chant. Dysphonia and ' 'Catch" in breath-* ing. Left Vocal Cord Five small Polypi. Practitioners since the Invention of the Laryngoscope. 231 Operator. Reference and Remarks. Evulsion with curved for- ceps ; subsequent cau- terization. Destruction with caustic solutions. Evulsion with crushing forceps and destruction with caustic solutions. Tracheotomy. Subse- quent evulsion through the mouth and cauteriza- tion. Evulsion with ecraseur ... Cauterization; subsequent evulsion and crushing. Partial removal with ecra- seur ; subsequent excision with knife. Evulsion with wire-ecra- seur. Improvement Improvement Improvement Cure ... Improvement Negative Cure ... Cure ... Evulsion with forceps and Cure subsequent cauterization. Tracheotomy. Growths subsequently removed with forceps through the mouth. Unsuccessful attempts being followed by great Dyspnoea, tracheotomy performed. Subsequent evulsion of Growth through mouth. Evulsion with ecraseur ... Evulsion with ecraseur ... Evulsion with loop-ecra- seur. Partial destruction with caustic solutions. Evulsion with forceps ... Evulsion of the largest Growth; cauterization of remainder. Improvement Improvement Great improve- ment. Cure ... Cure ... Great improve- ment. Cure ... Cure Fauvel Dr. Tiirck... Dr. Stoerk Rauchfuss... Gibb Dr. Lind- wurm. Professor Langen- beck. Dr.Trelat... Rauchfuss... Idem Idem Gibb Idem Elsberg Idem Idem Idem Gazette hebdomadaire, May 29, 1863. Klinik der Krankheiten des Kehl- kopfes, p. 311. Wagner's Archiv der Heilkunde, p. 238. Dr. Causit's Etudes sur les Polypes du Larynx. Paris, 1867, Case 39, p. 148. Patient was a deaf mute. Diseases op the Throat, &c., second edition, p. 151. Medical Times and Gazette, April 5, 1862 (Munich Correspondent). Gazette hebdomadaire, March 13, 1863. Ibid., May 1, 1863. Growth seen without laryngoscope. St. Petersburg medizin. Zeitschrift, 1864, p. 144. Ibid., p. 153. Patient continued to wear the tube. Breathing re- lieved, but hoarseness continued. Ibid., p. 45. Patient continued to wear the tube. Breathing re- lieved, but hoarseness continued. Diseases of the Throat, &-r., second edition, p. 152. Ibid., p. 153. Treatment of Morbid Grmvths within the Larynx. Philadelphia, 1866. Case 3. Ibid., Case 5. "A sufficiently loud and clear voice restored." Traces of the Growth remained. Ibid., Case 4. Ibid., Case 6. 232 Table of all published Cases treated by other No. of Case. Date. Sex. Age. Occupation. Symptoms. Situation. Pathological Nature. 51 1863 M. 22 Larynx and Epiglottis Benign (?) Epithelial Growth. 52 I863 M. 30 Tinsmith ... Dysphonia and Dys-pnoea. Posterior Wall Larynx. of Not stated 53 1863 M. 40 Hoarseness from Cushion of Epiglottis Peduncu- childhood; Cough lated Tu- for 3 weeks. mour.. 54 1863 F. 35 Dysphonia and fatigue of Voice. Both Vocal Cords Not stated 55 1863 M. 11 Dysphagia, Dys-phonia, and Dys- Epiglottis Cystic Growth. 56 1863 M. 21 pnoea. Dyspnoea ... Upper Orifice of Fibro-cellu- Larynx. lar Polypi. 57 May 1863 F. 38 Aphonia and Dys-pnoea. Right Vocal Cord Cystic Growth. 58 May 6, 1863 M. 33 Merchant... Hoarseness Right Vocal Cord Fibroma ... 59 1863 F. 33 Aphonia ... Right Vocal Cord Papilloma... 60 June 6, 1863 M. 34 Priest Hoarseness, Pain, and Sensation of foreign body. Right Vocal Cord Fibroma ... 61 June 24, 1863 M. 23 Merchant ... Hoarseness Right Vocal Cord Fibroma ... 62 July 1863 M. 3i Hoarseness, Pain in speaking. Right; Vocal Cord Fibroma ... 63 July F. 26 Hoarseness, Dys- Left Ventricular Fibroma ... 17, pnoea. Band. 1863 64 July, M. 43 Posterior Wall of Fibro- 1863 Larynx, filling half cellular the Glottis. Polypus. 65 Aug. 11, 1863 F. 24 Dysphonia and Dys-pnoea. Superior Orifice Larynx. of Papilloma... 66 Aug. M. Dyspnoea and Stri- One of the Vocal Not stated 1863 dor. Cords. 67 Oct. 25, 1863 M. 28 Left Vocal Cord Warty excre-scence, com- posed of fibrous tissue and epithe- lium. Practitioners since the Lnvention of the Laryngoscope. 233 Treatment. Result. Operator. Reference and Remarks. Partial evulsion with curved Improvement Czermak ... Medical Times and Gazette, May 30, forceps. 1863. Destruction with nitric Improvement Elsberg ... Treatment of Morbid Growths within acid and other applica- the Larynx. Philadelphia, 1866. tions. Case 7. Dyspnoea relieved; result as to voice not stated. Evulsion with wire loop... Cure ... Idem Ibid., Case 8. Abscission with Tobold's Cure ... Idem Ibid., Case 9. scissors. Incision with bistoury ... Cure ... Mr. Durham Medico - Cfururgical Tra nsactions, 1863. Sub-hyoid Laryngotomy Cure ... Dr.Follin... Archivesginerales de Medecine. Feb. and removal of Growth. 1867. Evulsion with ecraseur ... Cure ... Gibb Diseases of tke Throat, &=c., second edition, p. 154. Incision with knife, evul- Cure ... Bruns Die Laryngoskopie, 6r>c. Tubingen, sion with wire loop. 1865, p. 278. Destruction with crushing- Cure ... Tiirck Klinik der Krankheiten des Kehl- forceps, followed by cau- kopfes, p. 304. terization. Incision with knife, evul- Cure ... Bruns Die Laryngoskopie, &°c. Tubingen, sion with forceps. 1865, p. 287. Incision with knife, evul- Cure...... Idem Ibid., p. 298. sion with wire loop. Incision with knife, evul- Cure ... Idem Ibid., p. 301. sion with forceps. Preliminary Tracheotomy. Cure ... Idem Ibid., p. 307. Excision with scissors, evulsion with forceps and wire loop. Tracheotomy and division No benefit ... Dr. Busch Beobachtungen zur innern Klinik, of Thyroid and Cricoid von Carl Binz. Bonn, 1864, Cartilages. Growth evul- p. 108. Recurrence of Growth. sed, and application of galvanic-cautery. Tracheotomy, division of Death Dr. Boeckel Ex trait de la These deSwebel, Stras- Thyroid and Cricoid Car- bourg, 1866, quoted by Planchon tilages, and of Epiglottis; in his Faites cliniques de Trache- and removal of Growths. otomie, Paris, 1869. Patient died two months later of Pneumonia. Evulsion with ecraseur ... Cure ... Gibb Diseases of the Throat, tb^c, second edition, p. 155. No details given. Evulsion with guillotine... Cure ... Dr. Seme-leder. Wiener Medizinalhalle. 1864. 31 234 Table of all published Cases treated by other Date. Nov. 1863 Nov. 17, 1863 1863 1863 1863 Nov. 1863 Jan. 1, 1864 Jan. 2, 1864 Jan. 25, 1864 Mar. 1864 Mar. Mar. 1864 April, 1864 1864 April, 1864 May, May, 1864 Sex. Age. M. M. 52 22 26 44 29 47 29 Occupation. 64 49 Railway Porter. Charwoman Vocalist ... Symptoms. Lady Cabinet- maker. Servant Railway official. Singer Physician Lithographer Aphonia, Dys- pnoea, Dysphagia. Dysphonia Aphonia, attacks of Suffocation. Hoarseness, Suffo- cating Cough, Sensation of fo- reign body in Larynx. Dysphonia Dysphonia Aphonia Aphonia and severe hacking Cough. Hoarseness, Dys- pnoea. Voice extremely husky and feeble. Hoarseness, Sensa- tion as of a hair in Larynx. Hoarseness and occasional Apho- nia. Aphonia ... Hoarseness, Cough, Sensation of fo- reign body in Larynx. Dysphonia, subse- quent Aphonia and Pain. Dysphonia Dysphonia Situation. Left Vocal Cord and right Arytenoid Car- tilage. Ary-epiglottic Fold... Right Vocal Cord ... Right Vocal Cord ... Ary-epiglottic Fold... Right Vocal Cord ... Left Ventricular Band Ventricular Band ... Entire cavity of Larynx, except pos- terior portion of right Vocal Cord. Left Ventricle Right Vocal Cord ... Left Ventricle Left Vocal Cord ... Below left Vocal Cord Right Vocal Cord ... Left Vocal Cord Left Ventricle Left Vocal Cord Pathological Nature. Three separate Polypi. Large Fi- broma. Papilloma... Pedunculated Polyp. Polypus ... Fibroma Polypus Polypus Fibro- Epithelial Growth. Papilloma... Benign Epithelial Growth. Not stated Fibro- epithelial Growth. Papilloma.. Polypus .. Papilloma.. Cystic Growth. Papilloma. Practitioners since the Lnvention of the Laryngoscope. 235 Trentment. Result. Operator. Reference and Remarks. Evulsion with various in- Cure ... Dr. Seme- Wiener Medizinalhalle, 1864. struments. leder. Transverse incision through Death M. Debrou Gazette des Hopitaux, 1864, No. 46. Thyro-hyoid membrane, Patient died 7 days after operation, and Thyrotomy. Tra- with metastatic abscesses in both cheotomy subsequently lungs. performed. Destruction with crushing Great improve- Dr.Theodor Archiv der Heilkunde, p. 237 et seq. forceps. ment. Stark. " But slight hoarseness remained." Excision with guarded Cure ... Stoerk Wiener medizin. Wochenblatt, 1863, knife. No. 44. Evulsion with wire loop Cure ... Tre'lat Gazette des Hdpitaux, May 2, 1863. and cauterization. Excision with knife, sub- Cure ... Bruns Die Laryngoskopie, &c. Tubingen, sequent cauterization. 1865, p. 354. Destruction with galvanic- Improvement Idem Ibid., p. 365. cautery, after various unsuccessful treatment. Excision with knife Improvement Stoerk Wiener Wochenbl., xx. p. 22, 1864. Evulsion with cutting for- Negative Elsberg ... Treatment of Morbid Growths within ceps. the Larynx. Philadelphia, 1866. Tumour recurs as fast as it is removed ; division of Thyroid Car-tilage contemplated. Evulsion with wire loop... Improvement Bruns Die Laryngoskopie, &*c. Tubingen, 1865, p. 370. Evulsion with ecraseur ... Improvement Dr. George Transactions of Medico-Clururgical Johnson. Society, vol. Ii. Case I. "Voice still feeble and husky." Destruction by one appli- Cure ... Tiirck Klinik der Krankheiten des Kehl- cation of solid nitrate of kopfes, p. 310. It is very impro- silver. bable that this was a case of true Growth. Excision with cutting for- Cure ... Elsberg ... Treatment of Morbid Growths within ceps. the Larynx. Philadelphia, 1866. Excision with curved scis- Improvement Dr. Otto Archiv fur Heilkunde, 1866, p. 220. sors and cauterization. Prinz. Scarification, cauterization, Cure ... Idem Ibid., p. 222. and application of solu- tions of alum. Evulsion and galvanic Cure ... Bruns Die Laryngoskopie, &c. Tubingen, cautery. 1865, p. 389. Puncture with knife Cure ... Idem Ibid., p. 383. Evulsion with wire loop... Improvement Idem Ibid., p. 400. 236 Table of all published Cases treated by other No. Pathological of Dase Date. Sex. Age. Occupation. Symptom Situation. Nature. 86 Sum-mer of I 1864 M. 26 Dispenser... Hoarseness Right Vocal Cord .. Benign Epithelial Growth. 87 June 6, 1864 M. 39 Shepherd .. Hoarseness Right Vocal Cord ... Fibroma ... 88 July 20, 1864 M. 59 Civil Service official. Dysphonia Right Vocal Cord .. Fibroma ... 89 Oct. 10, 1864 M. 5 Aphonia ... Entire surface of La-rynx and upper part of Trachea. Papilloma... 90 Oct. 1864 Oct. M. 47 Gentleman Dysphonia Both Vocal Cords ... Papilloma... 9i M. 59 Gentleman Dysphonia Right Vocal Cord ... Fibroma ... 1864 92 Oct. F. 16 Hoarseness, I2yrs., Both Ventricles Polypoid 3i, Aphonia, and mass. 1864 Dyspnoea. 93 Dec. 1, M. 9k Hoarseness and at-tacks of Suffoca- Region of Vocal Cords Polypus ... 1864 tion. 94 1864 M. Consul Aphonia, with Left Ventricular Band Polypus ... great irritability of Palate. 95 Dec. 8, F. 6 Dyspnoea, and at-tacks of Suffoca- Entire cavity of Larynx and part of Trachea. Cauliflower Excrescence 1864 tion since months old. three 96 1865 M. 34 Professor ... Hoarseness Lower surface of Right Vocal Cord. Pedunculated Sarcoma. 97 1865 M. Soldier Aphonia ... Right Ventricle Fibroma ... 98 May 19, 1865 M. 59 Manager of Estates. Hoarseness Right Vocal Cord ... Benign Epithelial Growth. 99 June 29, 1865 M. 5° Lay-Agent Hoarseness Anterior insertion of Vocal Cords. Vascular Cyst. 00 1865 M. 5i Clergyman Hoarseness Cough. and Right Vocal Cord ... Two small Polypi. 01 June M. 52 Aphonia ... Left Vocal Cord ... Sarcoma, 29, rich in con- 1865 nective tissue. Practitioners since the Invention of the Laryngoscope. 237 Treatment. Result. Operator. Reference and Remarks. Evulsion with ecraseur ... Cure ... Johnson ... Transactions of Medico-Chirurgical Society, vol. Ii. Case 4. Destruction with galvanic- Cure ... Voltolini ... Die Anwendung der Galvano- cautery loop. caustic, &°c. Wien, 1867, p. 57. Excision with knife, and Cure... Brans Die Laryngoskopie, &>c. Tubingen, cauterization. 1865, p. 465. Removal with wire loop Improvement Idem Ibid., p. 322. Tracheotomy per- and scraper, and various formed before patient came under caustics; preceded by Dr. Bruns' care. Tracheotomy. Excision with knife and Cure ... Idem Ibid., p. 410. scissors. Incision with knife; evul- Cure ... Idem Ibid., p. 415. sion with wire loop. Tracheotomy, Thyrotomy, Cure ... Drs. Lewin Deutsche Klinik, 1865, No. 52, and removal of Growth. and Ulrich p. 510. Canula removed on third day. Tracheotomy. Subsequent Improvement M. Giraldes Gazette des HSpitaux, No. 140, 1867. excision with wire ecra- Patient wore canula for four years. seur. Diagnosis made with finger without aid of laryngoscope. Excision with curved scis- Improvement Dr. Tobold Berlin, klin. Wochenschrift, 1864, sors, forceps, and cau- No. 40, p. 386. terization. Dec. 4th, Tracheotomy. Improvement Prof. Gouley New York Medical fournal, Sep- Feb. 26, 1865, Division of tember, 1867, p. 473. In July, Thyroid and Cricoid Car- 1867, patient spoke in a loud tilages and removal of very distinct whisper, breathing Growth with scissors. quite natural. In November, operation repeated, and cauteriza- tion with chromic acid. Evulsion with forceps ... Improvement Tiirck Klinik der Krankheiten des Larynx, P- 576. Excision with Bruns' knife Cure ... Prinz Archiv fur Heilkunde, p. 223. and cauterization. Evulsion with ecraseur ... Great improve- Johnson ... Transactions of Medico- Chirurgical ment. Society, vol. Ii. Case 3. No re-currence in July, 1867, but cord uneven, and voice still gruff. Excision of Cyst with Cure ... Idem Ibid., Case 2. ecraseur. Destruction with solid ni- Improvement Voltolini ... Deutsche Klinik, 1865, p. 65. trate of silver. Excision with knife, and Cure ... Dr. Schroet- Wochenblatt der Wiener Aerzle, crushing forceps ; subse- ter. 9th August, 1865, No. 34. quent cauterization. 238 Table of all publisJied Cases treated by other Date. l865 l865 July, 1865 July 24, 1865 1865 1865 1865 1865 Dec. 21, 1865 Dec. 1865 1865 1865 1865 1865 Nov. 3, 1865 Dec. 3, 1865 Dec. 1865 Jan. 4, 1866 Sex. Age. M. 43 F. 54 F. 42 F. 44 M. 48 M. 57 M. 42 M. 33 M. 38 M. 39 F. 16 F. 54 M. M. 48 M. 40 M. 35 M. 38 M. 52 Occupation. Tradesman Locksmith Officer ... Actor Police In- spector. Innkeeper... Inspector of prisons. Schoolmaster Physician Police i spector. Mason Symptoms. Hoarseness Hoarseness Aphonia, Dys- pnoea, Cough. Aphonia, Dys- pnoea, Stridor, and Dysphagia. Hoarseness Cough. and Attacks of Suffoca- tion. Hoarseness Aphonia .. Hoarsenes and Stri- dulous breathing. Hoarseness Aphonia and severe Dyspnoea. Hoarseness, Dys- pnoea. Hoarseness, Dys- pnoea, Sensation of foreign body in Larynx. Dysphonia Hoarseness Hoarseness and tickling sensation. Situation. Right Vocal Cord ... Left Vocal Cord Numerous Growths in Larynx. Ventricle, and filling the Larynx. Right Vocal Cord ... Both Vocal Cords .. Right Ventricular Band and left Vocal Cord. Right Vocal Cord ... Left Vocal Cord and Ventricle. Anterior Commissure and both Vocal Cords. Anterior Commissure of Vocal Cords. Left Vocal Cord Anterior part of right Vocal Cord. Left Vocal Cord ... Both Vocal Cords and Ventricular Bands. Left Vocal Cord and left Ventricle. Left Vocal Cord Pathological Nature. Mucous Po- lypus. Fibroma ... Papilloma... Benign (?) Epithe- lioma; five tumours in all. Tumour of inflamma- tory infil- tration. Several Po- lypi. Benign (?) Epithe- lioma. Peduncu- lated Poly- pus. Papilloma... Papilloma.. Polypus .. Polypus .. Polypoid Growth. Polypus .. Fibroma ., Papilloma. Papilloma. Papilloma. Practitioners since the Invention of the Laryngoscope. 239 Treatment. Result. Operator. Reference and Remarks. Evulsion with ecraseur Cure ... Tiirck Klinik der Krankheiten des Kehl- and crushing forceps. kopfes, p. 299. Excision with crushing Cure ... Idem Ibid., p. 299. forceps. Excision with double-edged Cure ... Dr. Gottstein Berlin, klin. Wochenschrift, No. 46, pointed knife. 1865. Tracheotomy, division of Cure ... Prof. von Wienermedizin. Wochenschrift, Nov. Thyroid and Cricoid Balassa. 1868. Canula was removed, and Cartilages, and excision voice continued clear. of Growths with flat scissors. Destruction with crushing Improvement Tiirck Klinik dei- Krankheiten des Kehl- forceps. kopf es, p. 478. Thyrotomy, Excision with Improvement M. Koeberle Gazette des Hdpitaux, June 13, 1865. scissors, and cauteriza- tion. Excision with knife, and Improvement Dr. Emrich Berlin, klin. Wochenschrift, 1868, cauterization. Navratil. No. 48. Excision with knife, and Cure...... Idem Ibid., Vocal cord was wounded in cauterization. operation. Subsequent cure by faradization. Destruction with galvanic- Improvement Voltolini ... Archivfiir Heilkunde, 1866, p. 63. cautery wire loop. Evulsion with crushing Cure ... Tiirck Klinikder Kehlkopf krankheiten, p. 5 78. forceps. Growth recurred in 1866, and was treated by excision and cauteriza-tion. Thyrotomy and excision... Improvement Gilewski ... Wiener medizin. Wochensch., June 28, 1865, p. 142. Evulsion with crushing Cure ... Tiirck Klinik der Kehlkopf krankheiten, forceps. P- 309- Polyp-knife Improvement Stoerk Wiener Jahrbiiclur der k. k. Gesell-' schaft der Aerzte, No. 22, 1865. Laryngotomy and removal Cure ... Dr. Burow, Deutsche Klinik, vol. xvii. p. 165. through canular orifice. senior. Excision with knife and Cure ... Bruns Polyt>en des Kehlkopfes. Tiibingen, wire loop. 1868, p. 8. Destruction with wire loop, Improvement Idem Ibid., p. 2. scraper, and cauteriza- tion. Destruction with galvanic- Negative Voltolini ... Die Anwendung der Galvano- cautery wire loop. caustic, &c. Wien, 1867, p. 63. Patient still under treatment at time of publication. Destruction with galvanic- Cure ... Idem Ibid., p. 59. cautery wire loop. 240 Table of all published Cases treated by other No. of Date. Sex. Age. Case. 120 1866 M. 55 121 April, 1866 M. 56 122 April 28, 1866 M. 48 123 Aug. 1866 M. 74 124 April, 1866 F. 32 125 1866 M. 38 126 1866 M. 32 I27 1866 M. 47 128 1866 M. 46 129 1866 F. 15 130 1866 M. 35 131 1866 132 1866 M. 38 133 1866 M. 36 134 1866 M. 54 '35 1866 F. 28 I36 Dec. 7, 1866 F. 19 «37 1866 M. 42 138 1866 M. 39 Occupation Watchmaker Tax-agent... Teacher ... Clockmaker Charwoman Chimney- sweep. Mechanic Teacher ... Dyer Printer Single Lady Peasant Girl Merchant... Merchant ... Symptoms. Hoarseness Aphonia ... Hoarseness Pain. and Hoarseness, Dys- pnoea, and Stri- dor. Aphonia, Dys- pnoea, Cough,and Pain. Dysphonia Hoarseness, Cough, and Dyspnoea. Aphonia and Dys- pnoea. Aphonia ... Aphonia ... Severe Dyspnoea Aphonia and Dys- pnoea. Aphonia ... Hoarseness, Dys- pnoea, and Cough. Aphonia and Dys- pnoea. Hoarseness, Pain, and Dysphagia. Aphonia ... Aphonia and Dys- pnoea. Situation. Right Vocal Cord Right Vocal Cord Right Vocal Cord Left Vocal Cord Right Vocal Cord Right Vocal Cord Right Ventricle Right Vocal Cord fill- ing the Glottis. Right Vocal Cord ... Left Vocal Cord ... Right Vocal Cord ... Right Vocal Cord ... Right Vocal Cord ... Beneath Anterior Commissure. Whole lining mem- brane of Larynx. Left side of Larynx... Anterior Commissure Left Vocal Cord ... Right Vocal Cord ... Pathological Nature. Peduncu- lated Sar- coma. Myxoma , Fibroma Adenoma. Soft, nodular Tumour, with short Peduncle. Two small, whitish, fibrous Polypi. Benign (?) Epitheli- oma, Papilloma... Fibro-plastic growth. Cystic Tu- mour. Polypus ... Papilloma. Polypus ., Polypus . Papilloma. Papilloma. Papilloma... Soft Polypus Fibro-epi- thelial growth. Practitioners since the Invention of the Laryngoscope. 241 Treatment. Excision with knife Evulsion with wire loop... Partially removed with knife. Incision ; evulsion with forceps and wire loop. Evulsion with forceps, and cauterization. Cauterization with nitrate of silver and acetic acid. Thyrotomy (without pre- liminary Tracheotomy), and excision of Growth. Excision with double- edged polyp-knife. Excision with double- edged knife, and caus- tics. Excision with knife Destruction with galvanic- cautery loop. Excision with double- edged knife. Evulsion with wire loop... Excision with wire loop, knife, and hooks. Destruction with various instruments, galvano- cautery, &c. Excision with knife, cau- terization and galvanic cautery. Evulsion with wire loop... Excision with knife, and subsequent cauterization. Excision with Tobold's scissors and ecraseur. Result. Improvement Cure ... Improvement Cure ... Cure ... Improvement Cure ... Cure ... Improvement Cure ... Cure ... Cure ... Cure ... Improvement Negative Negative Cure ... Improvement Cure ... Operator. Tiirck Bruns Idem Idem Dr. Ludwig Mayer. Dr. Krish- aber. Balassa Dr. Schnitz- ler. Dr. Henry Oliver. Dr. Merkel Schnitzler .. Idem Professor Gerhardt. Idem Voltolini ... Idem Brans Navratil ... Dr. A. Rup- paner Reference and Remarks. Klinik der Kehlkopf krankheiten, P- 577- Polypen des Kchlkopfes. Tubingen, 1868, p. 17. Ibid., p. 23. Ibid., p. 30. Wiener medizin. Wochenschrift, 1866, No. 36, p. 375. Dr. Causit's Etudes sur les Polypes du Larynx, 1867, p. 150. Wiener medizin. Wochenschrift, 1868, No. 93. Wiener medizin. Presse, 1866, No. 50- A merican Journal of Medical Science, 1867, p. 115. A recurrence took place. Deutsche Klinik, No. 29, 1866. Wiener Wochenblatt der Aerzte, 1867, No. 3. Wiener medizin. Presse, 1867, Nos. 20, 26. Jahresberichte uber die Fortschritte. Virchow, vol. ii. p. 127. Ibid. Die Anwendung der Galvanocaustic, &*c. Wien, 1867, p. 50. Ibid., p. 51. Polypen des Kehlkopfes. Tubingen, 1868, p. 40. Berlin, klin. Wochenschrift, 1868, Nov. 30, p. 489. New York Medical Journal, vol. x. No. 4, p. 337. 32 242 Table of all published Cases treated by other Date. Sex. M. Age. 1866 Feb. F. 21 14, 1867 Feb. M. 68 1867 1867 M. 1867 M. 34 Mar. M. 37 1867 Mar. M. 38 7, 1867 April, F. 47 1867 April F. 19 30, 1867 April, M. 5o 1867 May M. 22 22, 1867 May M. 30 22, 1867 May, M. 8 1867 May M. 20, 1867 June, M. 1867 June M. 36 16, 1867 June, M. 66 1867 Aug. F. 25 1867 1867 M. 34 Occupation. Ragman ... Surgeon ... Carpenter... Judge Merchant.. Merchant. Chemist .. Clergyman Farmer Single lady Teacher ... Symptoms. Hoarseness and Dyspnoea. Aphonia ... Situation. Hoarseness Cough. and Aphonia ... Severe Dyspnoea. Aphonia ... Hoarseness Aphonia, Dyspnoea, sudden attacks of Suffocation. Aphonia, Dyspnoea, and attacks of Suffocation. Aphonia ... Aphonia ... Hoarseness Hoarseness and slight Dyspnoea. Aphonia and Dys- pnoea. Aphonia ... Hoarseness Hoarseness Hoarseness Hoarseness Pain. and Right Vocal Cord Both Vocal Cords Right Vocal Cord Not stated...... Posterior Wall of Trachea. Both Vocal Cords and Ventricular Bands. Left Vocal Cord Under surface of Right Vocal Cord. Below Vocal Cords... Both Vocal Cords and Ventricular Bands. Both Vocal Cords and Ventricular Bands. Left Vocal Cord ... Right Vocal Cord ... Not stated...... Right Vocal Cord ... Both Vocal Cords ... Right Vocal Cord ... Left Arytenoid region Left Vocal Cord Pathological Nature. Papilloma... Benign Epithelial Growth. Papilloma... Polypus ... Papilloma... Papilloma... Polypus ... Whitish gra- nular Epi- thelioma of hard con- sistence. Papilloma... Papilloma... Fibroma Benign Epithelial Growth. Fibroma ... Papilloma.. Polypus .. Papilloma.. Lipoma, with fibroid base. Fibroma Practitioners since the Invention of the Laryngoscope. 243 Treatment. Tracheotomy, and sub- sequent destruction of growth with galvano- cautery. Excision with polyp knife and cauterization. Excision with ecraseur ... Excision with knife and cauterization. Excision with forceps and application of astringents Evulsion with wire loop ... Evulsion with wire loop, scraping, and cauteriza- tion. Evulsion with curved for- ceps and cauterization. Tracheotomy, division of Thyroid and Cricoid Car- tilages, and excision of Growth. Evulsion with forceps and wire loop. Evulsion with wire loop and cauterization. Excision with knife Excision with ecraseur Tracheotomy and removal of Growth with forceps. Excision with knife and cauterization. Excision with wire loop and knife. Evulsion with wire loop... Destruction with galvanic- cautery, and excision with scissors and forceps. Excision with knife Operator. Improvement Cure ... Cure ... Cure ... Cure ... Improvement Cure ... Not stated ... Cure ... Improvement Improvement Cure ... Improvement Cure ... Improvement Cure ... Cure ... Improvement Improvement Reference and Remarks. Dr. Ventu- rini. Tobold ... Johnson ... Stoerk Schroetter Bruns Idem Dr. J. S. Cohen. Balassa Bruns Idem Idem Johnson ... Dr. Fournie Tobold ... Bruns Idem Idem Bruns Rivista clinica, April, 1867 ; and // Galvano - caustico nelie Mai. delta Laringe. Bologna, 1867, 127. Berlin, klin. Wochenblalt, 1869, Nos. 3 and 4. Transactions of Medico-Chirurgical Society, vol. Ii. Case 5. Wiener medizin. Wochenblalt, March, 27, 1867. Wiener Zeitschrift der Aerzte, 1867, P- 4°5- Poly pen des Kehlkopfes. Tubingen, 1868, p. 49. Ibid., p. 44. American Medical Journal, April, 1867, p. 404. Wiener medizin. Wochenschrift, November 11, 1868. Polypen des Kehlkopfes. Tiibingen, 1868, p. 54. Ibid., p. 59. Ibid., p. 64. Transactions of Medico-Chirurgical Society, vol. Ii. Case 6. "Voice somewhat reedy." Gazette des Hdpitaux, June 27, 1867. Berlin, klin. Wochenschrift, Dec. 30, 1867. Polypen des Kehlkopfes. Tubingen, 1868, p. 67. Ibid., p. 77. Ibid., p. 84. Polypen des Kehlkopfes. Tiibingen, 1868, p. 80. 244 Table of all publisJied Cases treated by otJicr No. of Date. Sex. Age. Occupation. Symptoms. Situation. Pathological Nature. Case. 158 Sept. 1867 M. 17 Engraver ... Attacks of Suffoca-tion. Below the Vocal Cords Polypus ... 159 1867 F. 46 Obstinate and severe Cough. Epiglottis Melanotic Growth. 160 Sept. 1867 M. 16 Aphonia ... Both Vocal Cords ... Papilloma... l6l Oct. 1867 M. 48 Gentleman Hoarseness Right Vocal Cord ... Benign Epithelial Growth. 162 Oct. 27, 1867 M. 32 Officer ... Hoarseness ... Left Vocal Cord Fibroma ... 163 Oct. 1867 M. 26 Banker Hoarseness ...' Right Vocal Cord ... Fibroma ... 164 Nov. 11, 1867 F. 13 Aphonia and Dys-pnoea. Both Vocal Cords and Ventricular Bands. Papilloma... 165 Nov. 1867 M. 32 Jeweller ... Aphonia ... Both Vocal Cords ... Papilloma... 166 Nov. 1867 M. 48 Weaver ... Aphonia ... Anterior Commissure Fibroma, with exten-sive ulcera- tion of Larynx. 167 Nov. 1867 M. 63 Hoarseness, Cough, and Dyspnoea. Entire lining mem-brane of Larynx. Papilloma.. 168 1867 M. 14 Hoarseness and Dyspnoea. Right Vocal Cord ... Papilloma... [69 Nov. 30, 1867 M. 59 Lawyer Aphonia, Dyspnoea, Cough, and Dys-phagia. Nearly whole of Larynx. Papilloma... 170 1867 M. 60 Druggist ... Intermittent Apho-nia. Vocal Cords... Two Polypi 171 1867 F. 21 Servant Aphonia and attacks of Suffocation. Below Vocal Cords... Sarcoma ... 172 1867 M. 40 Captain ... Hoarseness and Oppression in Throat. Beneath left Vocal Cord. Polypus ... 173 1867 M. 64 Aphonia since 17 years old; Dys-pnoea. Not stated...... Polypus ... 174 1867 34 Attacks of Suffoca- Posterior Wall of Polypus ... tion. Larynx. Practitioners since tJie Invention of tJie Laryngoscope. 245 Treatment. Result. Operator. Reference and Remarks. Tracheotomy. Evulsion of Growth with forceps and wire loop. Destruction with galvanic- cautery loop. Evulsion with wire loop and application of chromic acid. Excision with ecraseur ... Cure . Cure , Cure Cure Excision with annular knife; Cure Excision with knife Evulsion with wire loop and cauterization. Evulsion with wire loop and destruction with galvanic cautery. Evulsion with wire loop and cauterization. Evulsion with wire loop, destruction with galvanic cautery, and subsequently Tracheotomy. Evulsion with wire loop.. Evulsion with forceps ... Excision with polypotome and destruction with galvanic cautery. Tracheotomy Thyrotomy, and removal of Growth. Destruction with galvanic- cautery wire loop. Tracheotomy Evulsion with hook for- ceps, and application of astringents. Cure ... Improvement Cure ... Cure ... Improvement Cure ... Cure ... Cure ... Cure ... Cure ... Death Improvement Fournie Idem Tobold Johnson Bruns Idem Idem Idem Idem Idem Idem Dr. Ruppa- ner Voltolini ... Balassa Voltolini .. Dr. Uhde. Schroetter Gazette des HSpitaux, No. 56, il Ibid. Berlin, klin. Wochenblalt, 1869, No. 4. Two or three recurrences ; ultimate cure. Transactions of Medico-Chirurgical Society, vol. Ii. Case 7. Polypen des Kehlkopfes. Tiibingen, 1868, p. 106. Ibid., p. no. Ibid., p. 114. Tracheotomy had been performed in 1865; Canula removed Dec. 15, 1867. Ibid., p. 122. Ibid., p. 131. Ibid., p. 136. Ibid., p. 151. New York Medical Journal, vol. x. No. 4, P- 337- Die Anwendung der Galvano- caustic, &c. Wien, 1867, p. 53. Wiener medizin. Wochenschrift, No. 92, 1868. Patient returned with recurrence, Feb. 4, 1868. The Thyroid Cartilage was again divided, and the Growth removed without Tracheotomy. Bei-lin. klin. Wochenschrift, January 20, 1867, p. 27. Langenbeck's Archiv fiir klinische Chirurgie, vol. xi. p. 750. Jahresberichle iiber die Fottschritte. Virchow, 1867, vol. ii. p. 128. 246 Table of all publisJied Cases treated by otJier No. of Case. 175 t76 [77 .78 179 180 [81 [82 '83 184 '85 [86 [87 1867 1867 1867 Sex. Sept. 4, 1869 1869 1869 1870 1870 M. M. F. M. F. M. F. M. M. F. M. M. M. M. Age. Occupation. Wholesale Dealer. Clergyman Servant .. Merchant.. Girl Wine-Mer- chant. Symptoms. Situation. Hoarseness, Short- ness of breath. Aphonia, Dyspnoea, and attacks of Suf- focation. Hoarseness and Cough. Hoarseness Hoarseness Hoarseness Aphonia ... Hoarseness Aphonia ... Aphonia ... Hoarseness, Dys- pnoea, and Cough. Aphonia and Dys- pnoea. Aphonia and Dys- pnoea. Hoarseness and Oc- casional Aphonia. Aphonia, Dyspnoea, and Cough. Pathological Nature. Both Vocal Cords .. Left Ventricle Left Ventricle Left Vocal Cord Whole of right side and one-third of left side of Larynx. Under surface of left Vocal Cord. Both sides of Larynx Under surface of left Vocal Cord. Anterior Commissure of Vocal Cords. Left Ary-epiglottic Fold. Right Ventricle Beneath Vocal Cords Anterior Commissure of Vocal Cord. Beneath Anterior Commissure of Vocal Cords. Whole inner surface of Larynx. Sessile Tu- mour. Benign (?) Epitheli- oma. Uncertain... Fibroma ... Sarcoma ... Polypus (size of pea). Benign (?) Epitheli- oma. Polypus (size of small pea). Fasciculated Sarcoma- tous. Fibroma .. Fibroma .. Fibroma Papilloma... Fibroma ... Granular Pa- pilloma. Practitioners since tJie Lnvention of tJie Laryngoscope. 247 Treatment. Result. Operator. Reference and Remarks. Division through Thyro- Improvement Dr. Cutter... Boston Medical and Surgical hyoid Membrane, Thy- Journal, Feb. 1869. Recurrence roid and Cricoid Car- on Right Vocal Cord in less than tilages ; excision of one month. Growth with curved scis- sors and cauterization. Tracheotomy, excision Cure ... Dr. J. D. Ibid., 1869, p. 262. with forceps, and cau- Atlee. terization. Destruction with galvanic Cure ... Navratil ... Berlin, klin. Wochenschrift, 1868, cautery and astringents. No. 49, p. 500. Destruction with galvanic- Improvement Idem Ibid., p. 500. cautery porcelain knife. Excision with double-edged Improvement Idem Ibid., p. 501. knife and galvanic cau- tery. 1 Thyrotomy, and excision ' of growth with scissors ; Improvement Idem Ibid., p. 501. subsequent cauterization. Thyrotomy and Trache- Negative Idem Ibid., p. 501. otomy. Operation aban- doned. Thyrotomy, and excision Cure ... Idem Ibid., p. 502. of Growth. Excision with knife, wire Improvement Gottstein .. Wiener medizin. Wochenschrift, loop, and cauterization. Dec. 30, 1S6S, No. 105. Evulsion with forceps, Cure .. Stoerk Ibid., Nov. 18, 1868. scissors, and loop. Tracheotomy, Thyrotomy, Cure ... Krishaber... Gazette des Hopitaux, 1869, No. 103. and excision of Growth. Destruction with galvanic- Improvement M. L. Mandl LP Union midicale, 1869, p. 959. cautery knife. Evulsion with forceps and Improvement Dr. Guyon... V Union viedicale, 1870, p. 705. cauterization Evulsion with forceps and Cure ... Dr. Giuseppe 77 Morgagni, anno xii. Dispensa scissors. Gentile ... 6% 1870. Partial excision and Improvement Idem Ibid., Dispensa 9", 1870. cauterization. 1', ,;„«±y;. WWesUr, On GrozotJis in tJie Larynx. 249 DESCRIPTION OF PLATE II. Fig. 1, Case 23.—Papillomata on the Ventricular Bands and on both Vocal Cords. Fig. 2, Case 18.—Papilloma on the Right Vocal Cord. Fig. 3, Case 3.—Papillomatous Excrescences on nearly the entire Lining Membrane of Larynx. Fig. 4, Case 42.—Fibroma on the Right Vocal Cord. Fig. 5, Case 38.—Papilloma on the Posterior Wall of Larynx. Fig. 6, Case 25.—Cystic Tumour on the Epiglottis. Fig. 7, Case 57.—Papilloma on the Left Vocal Cord, and also on the Under Surface of the Epiglottis. Appearance in deep inspiration. Fig. 8.—The same. Appearance in forced expiration. Fig. 9.—The same. Rotation of the Growth beneath the Vocal Cord on attempted evulsion. Fig. 10, Case 52. —Fibro-cellular Growth on the Right Vocal Cord in situ, and after removal. Fig. 11, Case 64.—Papillomata on the Vocal Cords. Fig. 12, Case 89.—Angeioma in the Right Hyoid Fossa. 33 fromNature ft on StoriebyLenn-oxBror On Grozoths in tJie Larynx. 251 DESCRIPTION OF PEATE III. Figs. 1 and 2, Case 85.— Cystic Tumour on the Epiglottis. Fig. 3, Case 49.—Fasciculated Sarcoma on the under surface of the Epiglottis. Fig. 4, Case 88.—Adenoma on the Epiglottis. Fig. 5.—The Tumour after removal. Fig. 6, Case 79.—Adenoma beneath the Anterior Commissure of the Vocal Cords. Fig. 7, Case 95.—Fasciculated Sarcoma on the Right Ven- tricular Band. Appearance in inspiration. Fig. 8.—The same. Appearance in Phonation. Fig. 9.—The same. Tumour after removal. Fig. 10, Case 97.—Fibroma on the Posterior Wall of the Larynx. Fig. II, Case 99.—Fibro-cellular and Myxomatous Growth on both Vocal Cords. The Pink portion on the Right Vocal Cord is Myxomatous. Fig. 12.—The same twelve days after treatment was com- menced. ^1 :W?A- ■QO H On GrozvtJis in tJie Larynx. 253 DESCRIPTION OF PLATE IV. Fig. 1, Case 87.—Epithelioma of the Larynx. External Appearance during life. The canula, which is in the trachea, is surrounded by enormous excrescences growing from the wound and the surrounding skin. (For laryngoscopic appearance, vide Woodcuts 74 and 75.) Fig. 2.— The same. Appearance of Larynx after death, from behind. Fig. 3.—The same view, but the laryngeal canal has been divided by a perpendicular section. On Growths in the Laryn v. 255 DESCRIPTION OF PLATE V. Fig. 1, Case 98.—Benign Epithelial Growths on both the Vocal Cords, &c. Appearance after death. Fig. 2.—Eversion of the Right Ventricle ; Partial Eversion of the Left Ventricle. Appearance after death. (Page 34.) Fig. 3.__Growths in the Larynx of a dog. Appearance after death. (Page 55.) INDEX. A. PAGE. Acute Diseases, influence of, in Causation of Growths ............... 11 Adenomata, Laryngoscopic signs of 28 ,, Pathology of............... 52 Age, influence of, in causation of Growths............................... 13 Albers, his work on Tumours of the Larynx ................................. 3 Anaesthetics.......•.......................... 67 Angeiomata, Laryngoscopic Signs of 28 ,, Pathology of............... 53 Appendix A................................. 107 ,, B................................. 201 C................................. 209 I> .............................. 225 Atlee, Dr., his case, Appendix D ... 246 Auscultation of Larynx................. 31 B. Balassa, Professor von, his cases, Appendix D .................. 238 et seq. Benign Epithelial Growths, Laryngo- scopic signs of ........................ 26 Benign Epithelial Growths, Pathology of......................................... 46 Benign Epithelial Growths, situation of.......................................... 26 Boeckel, Dr., his case, Appendix D 232 PAGE. Bracey and Bolton, Messrs., their case, Appendix D .................. 228 Brauers, his case of Thyrotomy 1 and 92 Bruns, Professor von, his case of Lipoma................................. 49 Bruns, Professor von, his case of Myxoma................................. 48 Bruns, Professor von, his other cases, Appendix D .................. 228 el seq. Bruns, Professor von, on the disad- vantages of Galvanic Cautery...... 83 Buck, Dr. Gurdon, his cases of Growth...........................3, 92, 228 Burow, Dr., his case of Growth re- moved by infra-thyroid Laryn- gotomy ................................ 102 Busch, Dr., his case, Appendix D ... 232 C. Cartilaginous Tumours of Larynx 54 Catheter-shaped instruments, objec- tions to ................................ 64 Cases of Growths treated by the Author, detailed reports, Appen- dix A .................................... 107 Ditto, Tabular Statement of, Ap- pendix C .............................. 209 Cases of Growths, a few untreated, Appendix B ........................... 201 34 258 On GrozvtJis in tJie Larynx. Cases of Growths treated by other practitioners, Appendix D ......... 225 Causes of Growths ........................ 8 Causit, Dr., his remarks on influence of age.................................... 13 Caustics, Treatment by .................. 81 Chemical Treatment of Growths ...... 81 Chromic Acid, Treatment by ......... 82 Chronic Hyperaemia as a cause of Growths................................. 8 Clark, Dr. Andrew, on structure of Papillomata ........................... 41 Cohen, Dr., his case, Appendix D ... 242 Common Laryngeal Forceps............ 69 Comparative Pathology of Growths... 55 Complications of Growths............... 33 Compound Growths ..................... 53 Congenital origin of Growths ......... 14 Constitutional condition influenced by Growths................................. 32 Cooper, Sir Astley, his case of Growth ................................. 5 Cornil and Ranvier on Adenomata ... 52 Cough, a sign of Growths............... 21 Couper, Mr., his case, Thyrotomy Table.................................... 93 Course and Termination of Growths 32 Cricoid Cartilage should not be divided in Thyrotomy ........................ 91 Croup, as a cause of Growths ......... 12 ,, as a complication of Growths 58 Crushing, Treatment by ............... 73 Cutter, Dr., his case, Appendix D ... 246 Cutting, Treatment by .................. 73 Cutting Forceps ........................... 74 Cystic Growths, Laryngoscopic signs 28 ,, Pathology of......... 51 ,, situation of............ 28 ,, Treatment of......... 74 Czermak, Professor, his cases, Ap- pendix D......................... 228 et seq. Czermak, Professor, the first Growth seen with the Laryngoscope ...... 5 Czermak, Professor, on removal of Growths by infra-thyroid Laryn- gotomy ................................. 102 D. PAGE. Debrou, M., his case, Appendix D 234 Definition of Benign Growths ......... 1 Degeneration of Growths ............... 55 Destruction of Growths b y Caustics... 81 „ ,, Crushing... 73 ,, ,, Escharotics 82 „ ,, Galvanic Cautery 82 Diagnosis of Benign Growths from Malignant Growths .................. 36 Diagnosis of Laryngeal Growths from Condylomata........................... 35 Diagnosis of Laryngeal Growths from Elephantiasis........................... 36 Diagnosis of Laryngeal Growths from Eversion of the Ventricle............ 34 Diagnosis of Laryngeal Growths from False Excrescences .................. 36 Diagnosis of Laryngeal Growths from Lupus.................................... 3^ Diagnosis of Laryngeal Growths from Outgrowths ........................... 37 Diagnosis of Laryngeal Growths from Phthisis ................................. 36 Diagnosis of Laryngeal Growths from Syphilis................................. 35 Digital exploration of Growths......... 30 Division of the Cricoid Cartilage not necessary in Thyrotomy ............ 91 Division of the Crico-thyroid Mem- brane (infra-thyroid Laryngotomy) 102 Division of the Thyro-hyoid Mem- brane (supra-thyroid Laryngo- tomy) .................................... 98 Division of the Thyroid Cartilage (Thyrotomy) ........................... 88 Durham, Mr., his case of Cystic Growth, Appendix D ............... 232 Durham, Mr., his statistics of extra- laryngeal methods of treatment ... 95 Durham, Mr., on frequency of Growths 6 Dyscrasiae, influence of, in causation of Growths.............................. 8 Dysphagia, a sign of Growths ......... 24 Dyspnoea, a sign of Growths............ 22 On GrozvtJis in tJie Larynx. 259 Ecchondroses of Larynx ............ 54 Ecraseurs, Author's Guarded Wheel 79 Gibb's ........................ 76 ,, Johnson's ..................... 78 ,, Stoerk's........................ 78 ,, no danger in using ......... 79 Ehrmann, his case of Thyrotomy...... 92 ,, his treatise on Polypi of the Larynx.............................. 3 Elsberg, Dr., his cases, Appen- dix D ........................... 234 et seq. Elsberg, Dr., on Cutting Forceps ... 74 Enchondroma of Larynx ............... 54 Epiglottis, how often affected with Growths................................. 25 Epiglottis, when long or oblique, an impediment to treatment............ 68 Esch arotics, Treatment by ............ 82 Evans, Mr., his case, Thyrotomy Table 93 Eversion of the Ventricle may be mis- taken for Growths..................... 34 Evulsion of Growths ..................... 68 Extra-laryngeal methods of treat- ment, indications for ............... 84 Extra-laryngeal methods of treat- ment, contra-indications for ...... 86 Fasciculated Sarcomata, Laryn- goscopic signs of ..................... 27 Fasciculated Sarcomata, Pathology of 50 (J ,, situations of 27 Fauvel, Dr., his forceps.................. 69 „ his cases, Appendix D 226 et seq. Fenestrated Knife, Tiirck's ............ 79 Fibro-cellular Growths, Laryngosco- pic Signs of ........................... 2" Fibro-cellular Growths, Pathology of 47 ,, situations of 27 Fibro-epithelial Growths, Pathologyof 53 Fibromata, Laryngoscopic Signs of... 26 ,, Pathologyof ............... 46 ,, situations of.................. 26 Fibro-plastic Tumours .................. 50 Foerster, on Blood-vessels of Papillo- mata .................................... 42 Follin, Dr., his case ..................... 99 Forced external elevation of Larynx as a means of examination ......... 30 Forceps, common Laryngeal, Lateral, and Antero-posterior ............... 69 Forceps, Cutting........................... 74 ,, Tube.............................. 71 Fournie, Dr., his cases, Appen- dix D .................................... 242 Functional Signs of Growths............ 18 G. Galvanic Cautery, disadvantages of.......................................... 83 Galvanic Cautery, Treatment by...... 82 Gentile, Dr., his case, Appendix D... 246 Gerhardt, Professor, his case, Ap- pendix D .............................. 240 Gibb, Sir G. D., his cases, Ap- pendix D ..................... 226 et seq. Gibb, Sir G. D., his Ecraseur ......... 76 Gilewski, Dr., his case, Appen- dix D .................................... 238 Giraldes, M., his case, Appendix D 236 Gottstein, Dr., his cases, Appen- dix D ........................... 238 et seq. Gouley, Professor, his case, Ap- pendix D .............................. 236 Green, Dr. Horace, his cases of Growth 4 Guillotines ................................. 79 Guyon, Dr., his case, Appendix D ... 246 H. Harlan, Dr., his remarks on syphi- litic nature of Growths............... 9 260 On Growtlis in tJie Larynx. PAGE. History of Growths ..................... 2 Holthouse, Mr., his case, Thyrotomy Table .................................... 92 Hydatids of Larynx ..................... 54 Hyoid Fossa, how often affected with Growths................................. 25 Krishaber, Dr., his cases, Appen- dix D ........................... 240 et seq. Krishaber, Dr., on division of Cricoid Cartilage in Thyrotomy ............ 91 Krishaber, on frequency of Growths 6 I. Ice, value of, in allaying Pharyngeal irritation................................. 68 Influence of acute diseases in Causa- tion of Growths........................ 11 Influence of age in ditto.................. 13 ,, ChronicHyperaemiaindo. 8 ,, Croup in ditto ............ 12 ,, Dyscrasiae in ditto ...... 8 ,, irritating vapours and particles of matter in ditto ......... 12 Influence of occupation in ditto ...... 16 ,, sex in ditto ............... 16 Infra-glottic Mirrors ..................... 103 Inter-arytenoid Fold, how often af- fected with Growths.................. 25 Internal treatment ........................ 62 Irritating vapours, &c., as a Causa- tion of Growths........................ 12 J. Johnson, Dr., his cases, Appen- dix D ........................... 234 et seq. Johnson, Dr., his Ecraseur ............ 78 K. Knauf, Dr., his case, Appendix D 228 Knives ....................................... 74 ,, Dr. Tobold's remarks on...... 64 Koderik, his case of Growth............ 2 Koerberle, M., his case, Appendix D 238 Lancet, Laryngeal ..................... 75 Langenbeck, Professor, his case, Ap- pendix D.............................. 230 Laryngeal Crotchets ..................... 28 Ecraseurs ..................... 76 Forceps, common............ 69 ,, Cutting ...........". 74 Sounds ........................ 28 Wire Loops .................. 79 Lewin, Dr., his cases of Growth, Appendix D .................. 226 et seq. Lewin, Dr., on mistaken diagnosis in cases of Growth ..................... 7 Lieutaud, his cases of Laryngeal Growth ...................\............. 2 Lindwurm, Dr., his case, Appen- dix D ...............*................... 230 Lipomata, Laryngoscopic Signs of ... 27 ,, Pathologyof.................. 49 London paste .............................. 82 Loops of rigid wire........................ 79 M. Mandl, Dr., his case, Appen- dix D .................................... 246 Mayer, Dr., his case, Appendix D ... 240 Merkel, Dr., his case, Appendix D... 240 ,, on Diphthonia............ 20 Microscopical examination of Laryn- geal Growths........................... 31 Middeldorpf, on Galvanic Cautery ... 82 ,, his cases of Growth ...... 3 Modification of Voice, a sign of Growths................................. in On GrowtJis in tJie Larynx. 261 Moxon, Dr., his case of Eversion of the Ventricle ........................... 34 Myxomata, Laryngoscopic Signs of... 27 ,, Pathologyof ............... 48 N. Navratil, his cases, Appendix D 238 et seq. Neudorfer's infra-glottic Mirrors ...... 103 Nitrate of silver, Treatment by......... 81 ,, ,, how applied ......... 82 O. Occupation, influence of, in causa- tion of Growths........................ 17 Oliver, Dr., his case, Appendix D ... 240 Ozanam, Dr., his case, Appendix D 228 P. Paget, Mr., on Pathology of Fibro- mata .................................... 47 Paget, Mr., ditto of Papillomata... 40 ,, ditto in relation to Warty Cancer ................................. 45 Pain, as a symptom of Growths, ...... 23 Papillomata, Laryngoscopic Signs of 25 ,, Pathologyof............... 39 ,, situations of............... 26 Pathology, Comparative ............... 55 ,, General remarks on ...... 38 ,, of Adenomata ............... 52 ,, Angeiomata ............... 53 ,, BenignEpithelialGrowths 46 ,, Compound Growths...... 53 ,, Cystic Growths............ 51 ,, Fasciculated Sarcomata '50 ., Fibro-cellular Growths 47 Pathology of Fibro-epithelial Growths 53 ,, Fibromata.................. 46 ,, Lipomata .................. 49 ,, Myxomata ............... 48 ,, Papillomata ............... 39 ,, ,, in relation to Warty Cancer ..................... 45 Percussion of Larynx..................... 31 Phthisis, influence of, in causation of Growths................................. 9 Physical Signs of Growths............... 24 Planchon, Dr., on Laryngotomy ...... 90 Posterior wall of Larynx, how often affected with Growths............... 25 Prat, his case of Growth............3 and 98 Prinz, Dr., his cases, Appendix D ... 234 Procedure, method of, in treat- ment .................................... 68 Prognosis of Growths in relation to Life....................................... 57 Prognosis of Growths in relation to Voice .................................... 59 R. Rauchfuss, Dr., his cases, Ap- pendix D........................ 226 et seq. Rectangular instruments, advantages of......................................... 65 Recurrent Fibroid Tumours ............ 50 Regnoli, his case of Growth ............ 4 Removal of Growths by combined method ................................. 105 Removal of Growths by Cutting ...... 73 ,, ,, Evulsion...... 68 ,, ,, Infra-thyroid Laryngotomy........................... 102 Removal of Growths by Supra-thyroid Laryngotomy........................... 98 Removal of Growths by Thyrotomy... 88 Reports of cases treated by Author, Appendix A ........................... 107 Reports of a few cases untreated, Appendix B ........................... 201 262 On Growths in tJie Larynx. PAGE, Rings of rigid wire........................ 79 Rokitansky, his cases of Growth...... 3 Ruppaner, Dr., his cases, Ap- pendix D........................ 240 et seq. Ryland, his treatise on Diseases of the Larynx ................................. 3 S. Sands, Dr., his case, Thyrotomy Table .................................... 92 Schnitzler, Dr., his cases, Appen- dix D .................................... 240 Schroetter, Dr., his cases, Appen- dix D ........................... 236 et seq. Schiippel, Dr., his examination of Dr. Bruns' case of Lipoma ......... 49 Schiippel, Dr., ditto of Myxoma... 48 Scissors, Laryngeal........................ 74 Semeleder, Dr., his cases, Appendix D 232 ,, on tube-forceps ...... 71 Several different kinds of Instruments required ................................. 63 Sex, influence of, in Causation of Growths................................. 16 Shears, Laryngeal ........................ 74 Signs of Growths, functional............ £ 8 ,, ,, physical ............ 24 Situations of Growths..................... 25 Spindle-celled Sarcoma.................. 50 Stark, Dr., his case, Appendix D ... 234 Stoerk, Dr., his cases, Appendix D 230 et seq. ,, his ecraseurs.............. 78 Supra-thyroid Laryngotomy............ 98 ,, ,, history of 98 ,, ,, merits, comparative, of ..................... 100 Supra-thyroid Laryngotomy, method of procedure ........................... 100 Supra-thyroid Laryngotomy, Dr. Fol- lin's case of.......................... 99 Supra-thyroid Laryngotomy, Dr. Prat's case of.......................... 98 PAGE. Symptoms of Growths, functional ... 18 „ „ physical ...... 24 Synonyms of Benign Growths ........ 1 Syphilis, influence of, in Causation of Growths................................. 9 Tabular Statement of cases treated by Author, Appendix C ............ 209 Tabular Statement of cases treated by other practitioners, Appendix D... 225 Thyrotomy, or division of Thyroid Cartilage .............................. 89 Thyrotomy, contra-indications for ... 89 ,, history of .................. 88 ,, indications for ............ 88 ,, merits, comparative, of... 91 ,, ,, in relation to Life 94 ,, ,, ,, Recurrence 97 „ ,, „ Voice...... 95 ,, method of procedure...... 89 „ Table ........................ 92 Tobold, Dr., his cases, Appendix D 236 et seq. „ his remarks on knives 64 Tracheotomy, the only safe palliative treatment.............................. 61 Treatment by Caustics .................. 81 ,, Chemical ..................... 81 ,, Combined method of ...... 105 ,, by Crushing .................. 73 ,, by Cutting..................... 73 ,, by Escharotics ............... 82 ,, by Evulsion .................. 68 ,, Extra-laryngeal............... 84 ,, by Galvanic Cautery ...... 82 ,, Internal........................ 62 ,, Mechanical .................. 67 ,, Palliative ..................... 61 ,, Preparatory measures for 67 ,, Radical ........................ 61 ,, Table of various methods of Author's.............................. 65 On GrozvtJis in tJie Larynx. 263 Treatment, Table of various methods of other operators..................... 66 Trelat, Dr., his case, Appendix D ... 226 Tube-forceps .............................. 71 Tiirck, Dr., his cases, Appendix D 230 et seq. ,, on Diphthonia ............ 20 Uhde, Dr., his case, Appendix D .. 244 Ulrich, Dr., his case, Appendix D ... 236 Venous Vascular Tumours ............ 53 Ventricular Bands, how often affected with Growths........................... 25 Venturini, Dr., his case, Appen- dix D .................................... 242 Virchow, on Dyscrasiae .................. 9 ,, on Pathology of Papillo- mata .................................... 42 Vocal Cords, how often affected with Growths ................................ 25 Voltolini, his cases, Appendix D 228 et seq. ,, on Galvanic Cautery......... 83 W. Walker, Dr., his case, Appendix D 228 Weiss, Dr., his case, Appendix D ... 228 Whole surface of Larynx, how often affected with Growths ............... 21 Wordsworth, Mr., his case, Thyro- tomy Table.............................. 93 FINIS. Wyman &* Sons, Printers, Great Queen Street, Lincoln's-Inn Fields, London, W.C. ESSAYS ON THROAT DISEASES. ESSAY No. I. HOARSENESS, LOSS OF VOICE, AND STRIDULOUS BREATHING, IN RELATION TO NERVO-MUSCULAR AFFECTIONS OF THE LARYNX. Second Edition. OPINIONS OF THE PRESS. " The nervous affections of the larynx present an almost untrodden field of inquiry. We believe the work before us embodies the first attempt which has "been made to discriminate between the several affections of its nervous apparatus, and to classify and treat them according to some scientific plan. . . . Dr. Mackenzie has worked in a new field in a scientific spirit, and the professions are under a great obligation to him for the progress he has already made in this unexplored region of clinical research."—Medical Titties and Gazette. July 25th, 1868. " No one has done in this country more than Dr. Mackenzie to elucidate the pathology and treatment of disease of the throat and air-passages so common in our climate. . . . The book is one which deserves the attention of the profession."—British Medical Journal August 1 st, 1868. " We welcome the appearance of this book as a valuable con- tribution to our knowledge of laryngeal disorders. . . . A good collection of cases, some few of which are illustrated by wood engravings, adds to the practical value of the book, and no medical man will fail to cull useful information from its pages."—British and Foreign Medico-Chirurgical Reviezo, October, t868. "The cases recorded are instructive, and are thoroughly illus- trative of the value of electricity in many forms of aphonia."— Practitioner, August, 1868. 35 BV THE SAME AUTHOR. Just Published, Third Edition, zcith several additional Illustrations and new matter, THE USE OF THE LARYNGOSCOPE. OPINIONS OF THE PRESS. (Second Edition^) " This new edition of a work already well known to the profession, does not require a lengthened notice from us ; it is sufficient to say that Dr. Mackenzie has considerably increased its value by the careful revision which he has given to it, and the new matter which he has introduced. Of all the works in this country which have described the application of Laryngoscopy and Rhinoscopy, that of Dr. Mac- kenzie is the clearest and most reliable guide, and the one which gives the greatest amount of useful information."—Lancet, Feb. 29th, 1868. " It is always satisfactory to the profession to find that new and so-called ' special' means of diagnosis and treatment are taken up by men who have a thorough insight into the whole circle of pro- fessional knowledge, and who, consequently, are not prone to that constant harping on one string, and abuse of one set of local remedies, which are the alleged vices of specialists. . . . This second edition is evidently a complete work, bearing the stamp of original treatment, and we are glad to see that it is undergoing translation into French."—Medical Times and Gazette, March 16th, 1867. " The first edition of Dr. Morell Mackenzie's work on the Laryngoscope appeared at the beginning of last year, and has already been exhausted. This was but a natural result of its merits. He has now issued a second and revised edition, which, we have no doubt, will more than sustain the reputation of its predecessor as a most complete treatise on this subject."—British Medical Journal, Dec. 1st, 1866. " The new edition, whilst possessing the advantages of its pre- decessor—completeness, conciseness, and perspicuity,—has been further improved by careful revision and amplification of the text, and by the addition of several new woodcuts. ... It is undoubtedly the best work of the kind hitherto published."—The British and Foreign Mcdico-Chirurgical Reviczv, January. 1867. 3 OPINIONS OF THE PRESS. (First Edition.) " It is a thoroughly practical book, and to all who desire to become acquainted with these methods of exploring and treating throat affections, it must prove of great value. Its author is already well known to the profession as an earnest and successful investi- gator of these forms of disease. . . . We have much satisfaction in recommending this book to the profession. It is just what such a treatise ought to be—brief, clear, and systematic ; whilst every page exhibits the results of the author's matured experience and reflection." —Edinburgh Medical Journal, March, 1865. " While Laryngoscopy was in its infancy, and before it had begun to engage to any extent the attention of the profession, it was studied with the greatest care and enthusiasm by the author of this treatise. A personal friend of Czermak's, who has done more than any other Continental physician to introduce the Laryngoscope into practice, he has profited by the opportunities which he thus possessed of becoming acquainted with the anatomy and morbid anatomy of the larynx. But he has done much more than this. As will be seen by a perusal of this treatise, he has modified the instruments at present in use for the examination of the larynx, and has invented others for therapeutical purposes. . . . Those who are anxious to study the diseases of the larynx and the mode of using the Laryn- goscope, cannot do better than purchase the treatise before us, as it is by far the best which has been published in this country, and is thoroughly to be relied upon."-—Glasgozc Medical Journal, April, 1865. " The book before us is not only a well got-up work, but is in every respect a useful manual to whoever, student or practitioner, may wish to know how to use the Laryngoscope. ... In addition to a most lucid and accurate description of the instrument, the mode of using it, and various ingenious appliances for introducing remedies and performing operations in the larynx, he gives a short and well- written history of its discovery. . . . The woodcuts throughout the book are excellent."—Dublin Medical Press, August 9th, 1865. " This book is well calculated to popularize the method of in- vestigation which passes under the name of Laryngoscopy. It is throughout amply illustrated by well-executed and very clear woodcuts, and we have no doubt ourselves that it will meet with a rapid and extensive sale."—Medical Times and Gazette, March 28th, 1865. " Dr. Mackenzie has given us all that is known up to the present time, both of the instrument and of its capabilities. The work is 4 well written, and the subject systematically treated."—British Medical Journal, January 28th, 1865. " Brief, but with sufficient detail, clear, excellently illustrated, and (no unimportant consideration) well printed, this book forms a capital guide to the art of Laryngoscopy."—Ranking's Abstract, July, 1865. " Much valuable information is to be derived from this excellent work; and, so far as we are aware, no work on the subject contains so much in so small compass. It deserves a place in the library of every intelligent reading physician. . . . The Appendix is devoted to an exceedingly interesting and instructive article on Rhinoscopy." —Philadelphia Medical and Surgical Reporter, October 14th, 1865. " This is a well-written monograph, excellently arranged, and answering the purpose for which it is intended. ... It will be seen that the author is not so special in his views as to exclude every other branch of the profession, but desires simply to make his art an adjuvant. We advise all of our readers who feel an interest in this subject to peruse this work."—St. Louis Medical and Surgical Journal, January, 1866. See also The Athenozum, March 18th, 1865 ; Medical Circular, February 15th, 1865 ; Medical Mirror, February, 1865 ; and other Medical Journals for 1865. DU LARYNGOSCOPE, &c. Par MORELL MACKENZIE. Traduit de f Anglais sur la 2de Edition par le Dr. Emile NICHOLAS. " Morell Mackenzie parait posseder a. un haut degre les qualites qui appartiennent a sa race : il est precis, il est methodique, il va droit au but pratique. Des figures bien faites et assez nombreuses facilitent d'ailleurs l'intelligence du texte."—Union Medicate, Juillet, 1867. " Ce petit manuel est remarquable par la precision, par la clarte avec laquelle I'auteur a expose le sujet. II mene son lecteur par la main, et lui fait traverser le plus habilement du monde les sentiers les plus difficiles. Pour cela, il se souvient toujours qu'il parle a des me'decms a qui il veut enseigner ce qu'il sait si bien."—Journal de Medecine, Septembre, 1867. Philadelphia, September, 1871. LINDSAY & BLAKLSTONhand enclosed a New Catalogue of their Medical, Dental, and Scientific Publications, in which will be found viczry new and important works, and new editions of others just issued by them. Devoting themselves entirely to the publication of works on Medicine and the collateral sciences, they are enabled to offer unusual facilities to authors in publishing and extending the sale of their works. They also pub- lish a Classified and Priced List of all the more important Attierican and English Medical Publications, Periodicals, &c, &c., which they keep on hand, or furnish to order, at the lowest prices. The Classified List, together with their Catalogue, they will furnish post free, by mail or otherwise, upon application. Foreign Medical Works, not on hand, are imported promptly to order. The following New Works and New Editions are now ready. Rindfletsch's Text-Book of Pathological Histology, translated from the German. With 208 Microscopical Illustrations. Waring's Manual of Practical Therapeutics. Second American from the Third London Edition. Mackenzie on Laryngeal Growths, with Chromo-Lithograph and other Illustrations. Harris' Principles and Practice of Dentistry, with over 400 Illustra- tions. Tenth Revised Edition. Meadows' Text-Book of Midwifery. From the Second London Edition. With Illustrations. • Duchenne's Localized Electrization, with Notes and Additions by the Translator, and Numerous Illustrations. Tanner and Meadow's Practical Treatise on the Diseases of In- fancy and Childhood, Second Edition, Revised and Enlarged. Lindsay & Blakiston's Physician's Visiting List for 1812. Various Sizes and Styles of Binding. Byford on the Uterus. A New Revised and Enlarged Edition. Dillnberger's Handy-Book of the Diseases of Women and Children. Tilt on the Change of Life in Woman. From Third London Edition. Acton on the Reproductive Organs. Third American from the Fifth London Edition. Pereira's Prescription Book. A New American, from the Fifteenth London Edition. Wythe's Pocket Dose and Symptom Book. A New Revised Edition. Trousseau's Lectures on Clinical Medicine. Vol. 4. Reynolds's Lectures on the Clinical Uses of Electricity. Williams on Pulmonary Consumption. London Edition. Gant's Science and Practice of Surgery. A New Text-Book of Sur- gery. With 470 New Illustrations. Biddle's Materia Medica. The Fourth Revised Edition. Paget's Surgical Pathology. The Third London Edition. Beasley's Druggist's Receipt-Book. Seventh American Edition. Anstie on Neuralgia, and the Diseases that Resemble it. Wright on Headaches. A New Edition. Fothergill on Digitalis; Its Mode of Action, Use, &c. LINDSAY AND BLAKISTON'S PUBLICATIONS. Anstie on Neuralgia. Neuralgia, and the Diseases that resemble it. By Francis E. Anstie, M.D., Author of " Stimidants and Narcotics, their Mutual Relations, dec." Lecturer on Medicine in Westminster Hospital School, &c, &c. Octavo. Price,...........$3.50 "The Representative Book of Medical Science."—London Lancet. Aitken's Science and Practice of Medicine. SECOND AMEEIOAM from the FIFTH LONDON EDITION. In 2 Volumes, containing 2000 Royal Octavo Pages, a COLORED MAP, a LITHOGRA- PHIC PLATE, and ONE HUNDRED AND THIRTY ILLUSTRATIONS ON WOOD. Price, bound in Cloth, bevelled boards .... $12.00 " " Leather .......14 00 Dr. Aitken's work is now the most comprehensive Text-Book on the Practice of Medicine in the English Language; the present edition has been enlarged and care- fully revised by the author, as well as by the American editor, Meridith Cltmer, M.D., the latter having made additions of original matter e4ual to nearly 500 pages of the English Edition, with special reference to the wants of the American Practitioner. Acton on the Functions and Disorders of the Reproductive Organs, new edition. In Childhood, Youth, Adult Age, and Advanced Life, considered in their Physiological, Social, and Moral Relations. By William Acton, M.R. C. S., etc. Third American from the Fifth London Edition. Care- fully revised by the author, with additions. Just Ready, octavo, $3.00 " We think Mr. Acton has done good service to society by grappling manfully with sexual vice, and wo trust that others, whose position as men of science and teachers enable them to speak with authority, will assist in combating and arresting the evils which it entails. We are of the opinion that the spirit which pervades it is one that does credit equally to the head and to the heart of the author."— The British and Fortign Mcdico-Chirurgical Review. Anstie on Stimulants and Narcotics. TJieir Mutual Relations, with Special Researches on the Action of Alcohol, Ether, and Chloroform on the Vital Organism. By Francis E. Anstie, M.D., Assistant Physician to Westminster Hospital, Lecturer on Materia Medica and Therapeutics, etc., etc. Octavo, . . . . $3.00 AltliaUS' Medical Electricity. A New and Very Much Enlarged Edition. A Theoretical and Practical Treatise, and its Use in the Treatment of Paralysis, Neuralgia, and other Diseases. By Julius Althaus M. D., Member of the Royal College of Physicians, &c. Second Edition, revised, enlarged, and for the most part rewritten. In One Volume Octavo, with a IAthographic Plate And sixty-two Illustrations on Wood Price, ... . . $5.00 Byford on the Uterus, second edition. On the Chronic Inflammation and Displacement of the Unimpregnatea Uterus. A New, Enlarged, and Thoroughly Revised Edition, with Numerous Illustrations. Now Ready. One volume. Octavo. $3.00 From Forhycr Barker, M.D., Professor of Obstetrics and Diseases of Women and Children in Bellevue Hospital Medical College. Some weeks ago I received a copy of your work on the Uterus. I have delayed acknowledging the favor until I could give the book a careful perusal. I have just finished a thorough reading of it. I feel personally indebted to you, not merely for the copy — which, of course, I should have bought — but for writing the book; and I think you have laid the Profession in this country under a load of obligation by giving them Buch a clear, concise, and practical treatise on a class of affections *hat even now is very little understood by the greater majority. From R. A. F. Penrose, M.D., Professor of Obstetrics in the University of Pennsylvania. Accept my thanks for the copy of your new work which you so kindly sent me. I have, as yet, not had time to give it the careful study it merits; but from the super- ficial inspection I have made, I find much that is most valuable. From S. G. Hubbard, M.D., Professor of Obstetrics in Tale College, New Haven. I was gratified by the receipt of your new work on the Uterus, and I thank you sin- cerely for it. I have spent all my leisure in its examination, and have derived both pleasure and profit from its perusal. It is commendable for its clearness and definite- ness as well as for the great practical common sense which pervades it. I am sure that it will prove a very useful treatise, not only to junior practitioners, but to those also among us who, from not having devoted themselves to the treatment of uterine disease, as a specialty, have neither time nor opportunity to make original investigations in this department, and are not, therefore, perfectly at home in its practice. From James P. White, Professor of Obstetrics and Diseases of Women and Children in the University of Buffalo. I have had time, as yet, to run over but few of the chapters of your work on the Uterus; I am most happy, however, in being able to say that, so far as I have read, it does credit to American authorship. It is concise and brief, and eminently practical. The work was certainly a desideratum, and will be especially useful to practitioners who can illy afford to purchase all or most of the works referred to in your preface. I Bhall examine it with much interest, and, no doubt, often consult it with profit. From G. S. Bedford, M.D., Professor of Obstetrics and Diseases of Women aud Children in the University of New York. On my return to the city I found on my table " Byford on the Uterus." The next day I commenced perusing it, and have read it from cover to cover. I need not say that, in my judgment, the book enhances your deserved reputation. You have, if my opin- ion be worth anything, given the Profession an excellent work, and one that is sensible and practical. Go on, my dear Doctor, and give us more of your experience. It is what the Profession most needs —the experience of good and ripe minds. RECENTLY PUBLISHED, THE SECOND EDITION OF Byford's Practice of Medicine and Surgery. Applied to the Diseases and Accidents Incident to Women. By W. H. Byford A.M., M.D., J'rujc.^or of Obstetrics and Diseases of Women and Children in the Chicago Medical College, &c, &c. The Second Edition Revised and Enlarged, with Additional Illustrations. One volume. Octavo..........$5.00 The rapid sale of the first edition of this book, which was exhausted in a little more than a year, has enabled the author to carefully revise the whole work, add many im- provements, and to make a large addition of new matter, without, however, materially increasing the size of the volume. This work treats well-nigh all the diseases incident to women, diseases and accidents of the vulva and perineum, stone in the bladder, inflammation of the vagina, menstrua- tion and its disorders, the uterus and its ailments, ovarian tumors, diseases of the mam- mse, puerperal convulsions, phlegmasia alba dolens, puerperal fever, fee. Its scope ia thus of the most extended character, yet the observations are concise but convey much practical information.—London Lancet. LINDSAY AND BLAKISTON'S PUBLICA1IONS. Beasley's Book of Prescriptions. A NEW, REVISED, AND ENLARGED EDITION. Containing 3000 Prescriptions, collected from the Practice of the most Eminent Physicians and Surgeons — English, French, and American; comprising also a Compendious History of ilie Materia Medica, Lists of the Doses of all Officinal and Established Preparations, and an Index of Diseases and their Remedies. By Henry Beasley. Second American from the last London Edition. Octavo. .... $4.00 " The editor, carefully selecting from the mass of materials at his disposal, has compiled a volume, in which both physician and druggist, prescriber and compounder, may find, under the head of each remedy, the man- ner In which that remedy may be most effectively administered, or combined with other medicines in the treatment of various diseases. The alphabetical arrangement adopted renders this easy; and the value of the ▼olume is still further enhanced by the short account given of each medicine, and the lists of doses of its several preparations. It is really a most useful and important publication, and, from the great aid which it Is capable of affording in prescribing, should be in the possession of every medical practitioner. Amongst other advantages is, that, by giving the prescriptions of some of the most able and successful practitioners of the day, it affords an insight into the methods of treatment pursued by them, and of the remedies which they chiefly employed in the treatment of different diseases." — Lancet. Beasley's Druggists' General Receipt Book. SEVENTH AMERICAN EDITION, REVISED AND IMPROVED. Comprising a copious Veterinary Formulary, numerous Receipts of Patent and Proprietary Medicines, Druggists' Nostrums, etc.; Perfumery and Cosmetics, Beverages, Dietetic Articles and Condiments, Trade Chemicals, Scientific Processes, and an Appendix of Useful Tables, by Henry Beasley, Author of the Booh of Prescriptions, etc., etc. Seventh American from the Last London Edition. Octavo.....$3.50 "This is one of the class of books that is indispensable to every Druggist and Pharmaceutist as a book of reference for such information as is wanted, not contained in works used in the regular line of his business, and we can recommend it as one of the best of the kind." — American Druggists' Circular. Barth & Roger's Manual of Auscultation and Percussion. A new American Translation from the Sixth French Edition. 16mo. $1.25. " This is one of the most useful and practical manuals of its sort that has ever yet appeared, and we can- not too strongly recommend it to every student of medicine. It is sufficiently comprehensive without being lengthy, and the principles, which are eminently sound, can easily be mastered and understood.""- Medical Record. Bouchardat's Annual Abstract Of Therapeutics, Materia Medica, Pharmacy, and Toxicology, for 1867, with an Original Memoir of Gout, Gravel, Urinary Cal- culi, &c. By A. Bouchardat, Professor of Hygiene to the Faculty of Medicine, Paris, &c. Translated and Edited by M. J. De Rosset, M. D., Adjunct to the Professor of Chemistry in the University oj Maryland. In one Volume. Price, in cloth, . . $1.50. WORKS BY DR. LIONEL S. BEALE, F.R.S., Fellow of the Royal College of Physicians, Physician to King's College Hospital. Seventh Thousand. Four Hundred Illustrations, some Colored. HOW TO WORK WITH THE MICROSCOPE. This work is a complete manual of microscopical manipulation, and contains a ful description of many new processes of investigation, with directions for examining objects under the highest powers, and for taking photographs of microscopic object. Octavo. Cloth. Price, $7.50. ON KIDNEY DISEASES, URINARY DEPOSITS, AND CALCULOUS DISORDERS:— The Third Edition. Including the Symptoms, Diagnosis, and Treatment of Urinary Diseases. With full Directions for the Chemical and Microscopical Analysis of the Urine in Health and Disease. 70 Plates, 415 figures, copied from Nature. Octavo. Price, $10.00. THE USE OF THE MICROSCOPE IN PRACTICAL MEDICINE. For Students and Practitioners, with full directions for examining the various secre- tions, &c. in the Microscope. 4th Edition. 500 Illustrations. Octavo. Price, $7.00. THE MYSTERY OF LIFE. An Essay in reply to Dr. Gull's Theory, with two Colored Plates. Price, $1.50. LIFE, MATTER, AND MIND; OR PROTOPLASM. With Original Observations on Minute Structure, and numerous New Colored Drawings. A New Edition, very much enlarged. Eight Plates. Price, $ DISEASE GERMS: THEIR SUPPOSED NATURE. With Colored Plates. An Original Investigation with the Aid of the Highest Powers yet made. This work contains a critical examination of Dr. Tyndall's statements con- cerning ' Dust and Disease.' 12mo. Cloth. Price, $1.75. DISEASE GERMS: THEIR REAL NATURE. Twenty-four Plates. An Original Investigation. Twenty-four Plates, sixteen of which are Colored. Including the minute pathology of contagious diseases. Price, $4.00. Now ready. Four Colored Plates. PHYSICAL THEORIES OF LIFE: THEIR INFLUENCE UPON RE- LIGIOUS THOUGHT. Price $2.50. With Observations on the Hypotheses recently advocated by Tyndall and Huxley. ON DISEASES OF THE LIVER, AND THEIR TREATMENT. A Second Edition, much enlarged, of the Author's Work on the Anatomy of the Liver. Numerous Plates. Preparing. THE ARCHIVES OF MEDICINE. Part XVII. now ready. Price, $1.50. Contents.—Medicine under the Romans—Action of Eyelids in Expiration; P. C. Donders, Utrecht—Lacunae and Canaliculi—Nerves in Mesenteric Glands; Dr. Popper, St. Petersburg—German Criticism and British Medical Science—Homology of Coracoacromial Ligament; J. B. Perrin—Sulpho-carbolates, by Dr. Sansom— Structure of the Liver; Editor—Sputum in Phthisis. DISEASE: ITS NATURE AND TREATMENT. Preparing. New Researches on Inflammation and Fever, and on the Nature of Contagion. With Observations on the Cattle Plague and on Cholera. Numerous Colored Plates. Being the Third Course of Lectures delivered at Oxford by direction of the Radcliffe Trustees. All these Works contain the results of the Authors original investigations. They are Illustrated with upwards of 2000 Engravings, copied from the actual objects, all of which have been dravm hi word by the Author himself, or under his immediate superintendence. LIKDSAY & BLAKISTON, Publishers, Philadelphia. LINDSAY AND BLAKISTON's PUBLICATIONS. Biddle's Materia Medica. foltkth edition. For the Use of Students. With Illustrations. By J. B. Biddle, M.D., Professor of Materia Medica and Therapeutics in the Jefferson Med- ical College, Philadelphia, &c, &c. Revised and Enlarged. $4.00 This is a thoroughly revised and enlarged edition of Prof. Biddle's work on Materia Medica. It is designed to present the leading facts and principles usually comprised under this head as set forth by the standard authorities, and to fill a vacuum which seems to exist in the want of an elementary work on the subject. The larger works usually recommended as text-books in our Medical schools are too voluminous for convenient use. This will be found to contain, in a condensed form, all that is most valuable, and will supply students with a reliable guide to the courses of lectures on Materia Medica as delivered at the various Medical schools in the United States. Bull on the Maternal Management of Chil- dren in Health and Disease. . . 81.25 Birch on Constipated Bowels. The Various Causes and the Different Means of Cure. By S. B. Birch, M.D., Member of the Royal College of Physicians of London, &c. Third Edition. Price,.......$1.00 Braithwaite's Epitome of the Retrospect of Practical Medicine and Surgery. 2V0K $10.00 Chambers on the Renewal of Life. Lectures chiefly Clinical, illustrative of a Restorative System of Medi- cine. By Thos. K. Chambers, M.D., Physician to St. Mary's Hos- pital, author of " The Indigestions," &c, &c A new American from the Fourth London Edition. Octavo, . . . $5.00 " This work is of the highest merit, written in a clear, masterly style, and devoid of technicalities. It is simply what it professes to be, Lectures Clinical, delivered from cases observed at the bedside; therefore more valuable as enunciating the views and experiences of a practical mind aided by actual observation. They are of deep interest, and replete with facts having a practical bearing, and will well repay perusal."—Canada Medical Journal. Chew on Medical Education. A Course of Lectures on the Proper Method of Studying Medicine. By Samuel Chew, M.D., Professor of the Practice and Principles of Medicine and of Clinical Medicine in the University of Maryland. $1.00 "Dr. Chew was an eminent member of the medical profession, and a well-known teacher of medicine. He was, therefore, well fitted for the judicious performance of this task, upon which he seems to have entered with interest and pleasure. It is a well-timed book, and will serve as a most excellent manual for the student, as well as a refreshing and suggestive one to the practitioner." — Lancet and Observer. Cazeaux's Great Work on Obstetrics. THE MOST COMPLETE TEXT-BOOK NOW PUBLISHED. GREATLY ENLARGED AND IMPROVED. CONTAINING 175 ILLUSTRATIONS. A Theoretical and Practical Treatise on Midwifery, including the Disease* of Pregnancy and Parturition, by P. Cazeaux, Member of the Imperial Academy of Medicine; Adjunct Professor in the Faculty of Medicine of Paris, etc., etc. Revised and Annotated by S. Tarnier, Adjunct Pro- fessor in the Faculty of Medicine of Paris; Former Clinical Chief of the Lying-in-Hospital, etc., etc. Fifth American from the Seventh French, Edi- tion. Translated by Wji. R. Bullock, M. D. In one volume Royal Oc- tavo, of over 1100 pages, with numerous Lithographic and other Illustra- tions on Wood. Price, bound in Cloth, bevelled boards, . . . $6.50 " Leather, . .....7.50 M. Cazeaux's Great Work on Obstetrics has become classical in its character, and almost an Encyclopaedia in its fulness. Written expressly for the use of students of medicine, and those of midwifery especially, its teachings are plain and explicit, present- ing a condensed summary of the leading principles established by the masters of the obstetric art, and such clear, practical directions for the management of the pregnant, parturient, and puerperal states, as have been sanctioned by the most authoritative practitioners, and confirmed by the author's own experience. Collecting his materials from the writings of the entire body of antecedent writers, carefully testing their correct- ness and value by his own daily experience, and rejecting all such as were falsified by the numerous cases brought under his own immediate observation, he has formed out of them a body of doctrine, and a system of practical rules, which he illustrates and enforces in the clearest and most simple manner possible. OPINIONS OF THE PRESS. " It is unquestionably a work of the highest excellence, rich in information, and perhaps fuller in details than any text-book with which we are acquainted. The author has not merely treated of every ques- tion which relates to the business of parturition, but he has done so with judgment and ability." British and Foreign Medico-Chirurgical Review. " The translation of Dr. Bullock is remarkably well done. We can recommend this work to those especially interested in the subjects treated, and can especially recommend the American edition." Medical Times and Gazette. " The edition before us is one of unquestionable excellence. Every portion of it has undergone a thorough revision, and no little modification; while copious and important additions have been made to nea-ly every part of it. It is well and beautifully illustrated by numerous wood and lithographic engravings, and, in typographical execution, will bear a favorable comparison with other works of the same class."—American Medical Journal. "In the multitudinous collection of works devoted to the propagation of human beings, and to the details of parturition, none, in our estimation, bears any comparison to the work of Cazeaux, in its ectiro perfectness; and if we were called upon to rely alone on one work on accouchments, our choice woulj fall upon the book before us without any kind of hesitation."— West. Jour, of Med. ar.J Surgery. "We do not hesitate to say, that it is now the most complete and best treatise on the subject in the English language."— Buffalo Medical Journal. "We know of no work on this all-important branch of our profession that we can recommend to the liudent or practitioner as a safe guide before this."— Chicago Medical Journal. " Among the many valuable treatises on the science and art of obstetrics, the work of Cazeaux standi pre-eminent."— St. Louis Med. and Surg. Journal. " M. Cazeaux's book is the most complete we have ever seen upon the subject. It is well translated, %nd reflects great credit upon D-. Bullock's intelligence and industry."— N. A. Medi.i-c- Chirurg. Revieu LINDSAY AND BLAKISTON's PUBLICATIONS. Cleaveland's Pronouncing Medical Lexicon. Containing the Correct Pronunciation and Definition of most of the Terms used by Speakers and Writers of Medicine and the Collateral Sciences. By C. H. Cleaveland, M.D., Member of the American Medical Association, &c, &c. A New and Improved Edition. $1.25 This little work is not only a Lexicon of all the words in common use in Medicine, but it is also a Pronouncing Dictionary, a feature of great value to Medical Students. To the Dispenser it will prove an excellent aid, and also to the Pharmaceutical Student. It contains a List of the Abbreviations used in Prescriptions, together with their mean- ing ; and also of Poisons and their Antidotes. It has received strong commendation both from the Medical Press and from the profession. Cohen on Inhalation. Its Therapeutics and Practice. A Treatise on the Inhalation of Gases, Vapors, Nebulized Fluids, and Powders ; including a Description of the Apparatus employed, and a Record of Numerous Experiments, Physiological and Pathological; with Cases and Illustrations. By I. Solis Cohen, M.D. 12mo. Price,.....$2.50 "We recognize in this book the work of a persevering Physician who has faithfully Btuiied his subject, and added to its literature much that is useful from his own expe- rience. Dr. Cohen has given us briefly and clearly whatever is valuable in relation to the insufflation of powders in respiratory affections, with the experimental proofs and pathological evidence of their penetration into the bronchial tubes and lung tissues." American Journal of Medical Science, July, 1868. Carson's History of the Medical Department Of the University of Pennsylvania, from its Foundation in It65: with Sketches of Deceased Professors, &c. By Joseph Carson, M.D., Professor of Materia Medica and Pharmacy in the University. $2.00 '« The history of the University of Pennsylvania has a national as well as a local interest, from the early date of its origination, and the connection with it of men of illustrious public reputation, such as Drs. Franklin, Rush, Physick, Gibson, Dewees Chapman, Wood, &c, &c. For the labor and love which he has spent in preparing thi3 most interesting and valuable work, Prof. Carson has earned the gratitude of the alumni of the University, and of all others interested in medical education in this country." — American Journal of Medical Science. Dixon on the Eye. A Guide to the Practical Study of Diseases of the Eye, with an Outline of their Medical and Operative Treatment, with Test Types and Illus- trations. Third Edition, thoroughly Revised, and a great portion Re- written. By James Dixon, F.R.C.S., Surgeon to the Royal London Ophthalmic Hospital, &c, &c. In one volume. Price, . $2.50 "Mr. Dixon's book is essentially a practical one, written by an observant author, wno brings to his special subject a sound knowledge of general Medicine and Sur- gery."— Dublin Quarterly. LINDSAY AND BLAKISTON'S PUBLICATIONS. Duchenne's Localized Electrization. Translated from the Third Edition, by Herbert Tibbits, M.D., L.R. C.P., Lond., Medical Superintendent of the National Hospital for the Paralyzed and Epileptic. With 92 Illustrations, and Notes and Addi- tions by the Translator. Price, . ... $3.00 CONTENTS OF PART I. Chapter II. Localized Electrization. — Part I. The Fundamental Principles of the Method. Part 2. Localized Muscular Electrization. Part 3. Cutaneous Electriza- tion. Part 4. Faradization of Internal Organs, the Genital Organs, and Organs of Sense. Part 5. The General Effects of Localized Faradization. Chapter III. Historical and Critical Observations upon the Principal Methods of Electrization.—Parti. On the Value of Electro-puncture as applied to the Treatment of Paralysis. Part 2. On the Value of Electrization by Reflex Action as applied to the Treatment of Paralysis. Part 3. On the Therapeutic Value of Local- ized Faradization. Chapter IV. Electro-Medical Instruments with regard to their Application in Pathology, in Physiology, and in Therapeutics. — Part 1. The Properties which Instruments should possess. Part 2. The Author's large Double-current Volta- Faradic Instrument. Part 3. Small Double-current Volta-Faradic Instrument. Part 4. The Author's Double-current Magneto-Faradic Instrument. Part 5. His- torical and Descriptive Account of Inductive Instruments. This part of Duchenne's great work is a translation from the third edition now being prepared by the author, and contains all that has yet been printed, and is published even before the original is issued. It is not only a well-nigh exhaustive treatise on the medical uses of Electricity, but it is also an elaborate exposition of the different diseases in which Electricity has proved to be of value as a therapeutic and diagnostic agent. No similar treatise, it is believed, exists in the English language. Part IL, illustrated by chromo-lithographs and numerous wood-cuts, is preparing. " Duchenne's great work has for years held its place as the most complete; and Dr. Tibbits, by presenting us with an English version of the forthcoming third edition, has earned the gratitude of the profession. His experience at the National Hospital gives great value to his Notes and Additions, and we are happy to congratulate him upon having so far accomplished an undertaking of great utility."—The Lancet. Dillnberger's Handy-Book of the Treatment of Women and Children's Diseases, according to the Vienna Medical School. Part I. The Diseases of Women. Part II. The Diseases of Children. Translated from the Second German Edition, by P. Nicol, M.D. One volume 12mo. Price,.......$1.75 "We noticed favorably the original of this hand-book some months ago, and sug- gested that an English translation of it, with notes showing the main points wherein the practice of our medical schools differs from that at Vienna, might he well received. Mr. Nicol has now carried out this idea, and we imagine that many practitioners will be glad to possess this little manual, which gives a large mass of practical hints respecting the treatment of diseases which probably make up the larger half of every- day practice. The translation is well and correctly performed, and the necessary explanations of reference to German medicinal preparations are given with proper fulness." — The Practitioner. LINDSAY AND BLAKISTON'S PUBLICATIONS. Durkee on Gonorrhoea and Syphilis. The Fifth Edition, Revised and Enlarged, with Portraits and Colored Illustrations. By Silas Durkee, M.D., Fellow of the Massachusetts Medical Society, &c, &c. A New and Revised Edition, with Eight Colored Illustrations. Octavo, ...... $5.00 "Dr. Durkee's work is one of those, the perusal of which impresses the reader in favor of the author. The general tone, the thorough honesty everywhere evinced, the philanthropic spirit observable in many passages, and the energetic advocacy of pro- fessional rectitude, speak highly of the moral excellence of the writer; nor is the reader less attracted by the skill with which the book is arranged, the manner in which the facts are cited, the clever way in which the author's experience is brought in, and the lucidity of the reasoning, the frequent and extremely fair allusions to the labors of others, and the care with which the therapeutics of venereal complaints are treated." —Lancet. Fuller on Rheumatism, Rheumatic Gout, and Sciatica, a new edition preparing. Flint's Reports on Continued Fever, With an Analysis of 164 cases &c, &c. By Austin Flint, M.D. &c, &c. Octavo. Price,.........$2.00 Fuller on Diseases of the Heart and Great V eSSelS. The Second Edition, preparing. Fothergill on Digitalis: Its Mode of Action, and its Use, 12mo. Cloth. . . . • $1.25 Gant's Science and Practice of Surgery. A Complete System, including the Principles and Practice, by Freder- ick J. Gant, F.R.C.S., Surgeon to the Royal Free Hospital, London, &c, &c. With 470 Illustrations. Price, . . . . $7.50 Dr. Gant's Surgery is similar in its general features to Dr. Errickson's excellent Text-book on the Science and Practice, as comprising the whole of surgery, but it will have the great advantage of being an entirely new work, and appearing in a greatly condensed form, without the omission of any important subject. The matter through- out is fully brought up to the present time, — many original sources of information, including the best treatises in Holmes' System of Surgery, having been utilized which have not heretofore been gathered into any general work on surgery, thus making it a more complete book for the student, and a work of ready reference for the practi- tioner. It is also illustrated by 470 new illustrations, which add much to its value. Goff's Combined Day-Book, Ledger, and Dauy Register of Patients, combining not only the Accuracy and Essential Points of a regular Day-Book and Ledger System, without any of the labor and responsibility, but is also a Daily Register of Patients, &c, &c. A large Quarto Volume, strongly bound in half-russia. Price, $12.00. LZNLSAY AND BLAKISTON'S PUBLICATIONS. Gioss' American Medical Biography of the Nineteenth Century. Edited by Samuel D. Gros3, M.D., Professor of Surgery in the Jefferson Medical College, Philadelphia, &c, &c. With a Portrait of Benjamin Rush, M.D. Octavo.........$3.50 Greenhow on Bronchitis, especially as connected with Gout, Emphysema, and Diseases of the Heart. By E. Headlam Green how, M.D., Fellow of the Royal College of Physicians, &c, &c. Price, $2.00 "In vivid pictures of the sort of cases which a practitioner encounters in his daily walks, and in examples of the way in which a student ought to turn them over in his mind and make them tools for self-improve. Bent, we have rarely seen a volume richer." — Brit, and For. Medico-Oiirurg. Xeview. Garratt's (Alfred C.) Guide for XJ^ing Medical Batteries. Showing the most approved Apparatus, Methods, and Rules for the Medical Employment of Electricity in the Treatment of Nervous Diseases, &c, &c. With numerous Illustrations. One Volume, octavo. . . $2.00 " The large work on the same subject, and by tVie same author, is pretty well known to the Profession, bui It is bulky and cumbrous, and by no means so practically useful. The present comparatively brief volume contains every thing of importance in regard to the various apparatuses useful to the Medical Electrician and the various modes of application foi therapeutic purposes." — Lancet and Observer. Hewitt on the Diseases of Women. SECOND EDITION, REWRITTEN AND ENLARGED. The Diagnosis and Treatment of Diseases of Women, including the Diagnosis of Pregnancy. Founded on a Course of Lectures deliverea at St. Mary's Hospital Medical School. By Graily Hewitt, M. D. Lond., M. R. C. P., Physician to the British Lying-in Hospital; Lec- turer on Midwifery and Diseases of Women and Children at St. Mary's Hospital Medical School; Honorary Secretary to the Obstetrical So- ciety of London, &c. With a new Series of Illustrations. Price, in cloth, $5.00; in leather, $6.00. Hillier's Clinical Treatise on the Diseases of OllllOren. By Thomas Hillier, M.D., Physician to the Hospital for Sick Children, and to University College Hospital, &c, &c. Octavo. Price. $3.00 "Our space is exhausted, but we have said enough to indicate and illustrate the excellence of Dr. HilUer« »olunie. It is eminently the kind of book needed by all niedi-jal men who w eh to cultivate cliDitai aciracj turf sound practice." — London Lancet. " It is thoroughly clinical and sound in its observation and practical application of experience. From the therapeutical point of view, which chiefly interests us, we may recommend it with great confidence; and it is certainly a very much needed work."— The Practitioner. " Each chapter is carefully written, and every line is thoroughly practical. The busy practitioner will find in its pages, within small compass, much to interest and to instruct him ; and to the student it will form a pleasant gateway to the knowledge of the diseases of early life." — Edinburgh Medical Journal. LINDSAY AND BLAKISTON'S PUBLICATIONS. Headland on the Action of Medicines in the I System, sixth American edition. By F. W. Headland, M.D., Fellow of the Royal College of Physician*, &c, &c. Sixth American from the Fourth London Edition. Revised and enlarged. One Volume, octavo......$3.00 Dr. Headland's work has been out of print in this country nearly two years, await- ing the revisions of the author, which now appear in this edition. It gives the only scientific and satisfactory view of the action of medicine; and this not in the way of idle speculation, but by demonstration and experiments, and inferences almost as in- disputable as demonstrations. It is truly a great scientific work in a small compass, and deserves to be the handbook of every lover of the Profession. It has received the most unqualified approbation of the Medical Press, both in this country and in Europe, and is pronounced by them to be the most original and practically useful work that has been published for many years. Hille's Pocket Anatomist. Being a Complete Description of the Anatomy of the Human Body; for the Use of Students. By M. W. Hilles, formerly Lecturer on Anatomy and Physiology at the Westminster Hospital School of Medicine. Price, in cloth,........$1.00 " in Pocket-book form,......1.25 Heath on the Injuries and Diseases of the Jaws. The Jacksonian Prize Essay of the Royal College of Surgeons of Eng- land, 186T. By Christopher Heath, F.R. OS., Assistant Surgeon to University College Hospital, and Teacher of Operative Surgery in Uni- versity College. Containing over 150 Illustrations. Octavo. Price, $6.0(5 Hodge on Foeticide, or Criminal Abortion. By Hugh L. Hodge, M.D., Emeritus Professor in the University of Pennsylvania. A Small Pocket Volume. Price in paper" covers, 30 flexible cloth, 50 This little book is intended to place in the hands of professional men and others the means of answering latisfactorily and intelligently any inquiries that may be made of them in connection wi»h this important lubject. Holmes' Surgical Diseases of Infancy and L nilClnOOCl. By J. Holmes, M.A., Sui gem to the Hospital fo* Siok Children, &c. Second Edition. Revised and Enlarged. Octavo. Price, $9.00 Hufeland's Art of Prolonging Life. Edited bV ■ Erasmus Wilson, M.D., P.R.S. Author of liA System of Human Anatomy,'' " Diseases of the Skin,u &c, &c. 12mo. Cloth. $1.25 LINDSAY AND BLAKISTON'S PUBLICATIONS. Kirkes' Hand-Book of Physiology. THE SEVENTH LONDON EDITION. HAND-BOOK OF PHYSIOLOGY, by William Senhouse Kirkes, M.D. Seventh Edition, edited by W. Morrant Baker, F.R.C.S., Lee turer on Physiology, &c, &c. With 241 Illustrations. In one volume, demy-octavo, containing over 800 pages. Price, bound in cloth, $5.00. This edition of Dr. Kirkes' Hand-Book of Physiology is fully brought up to the times, and forms one of the most complete and convenient Text-Books on the subject, for the Student of Medicine, now in print. Lawson on the Eye. The Diseases and Injuries of the Eye, their Medical and Surgical Treatment. By George Lawson, F.R.C.S., Surgeon to the Royal London Ophthalmic Hospital, &c, &c. With a Formulary, Test Types, and numerous Illustrations. In one volume. Price, . . $2.50 "Dr. Lawson has succeeded in comprising within moderate limits a very complete and succinct account of the Diseases and Injuries of the Eye." " The many excellent features of this manual render it at once a safe and thoroughly trustworthy guide to the study of this special class of diseases, and from its eminently practical character it must be a great acquisition to the library of the busy practitioner. Its value is also much enhanced by an excellent selection of formulae." — Glasgow Med. Journal. Legg on U line, from the second London edition. A Guide to the Examination of the Urine. For the Practitioner and Student. By J. Wickham Legg, M.D., Member of the Royal College of Physicians, &c, &c. Second Edition. 16mo. Cloth. Price, 15 cts. "Dr. Legg's little manual has met with remarkable success, and the speedy exhaustion of the first edition has enabled the author to make certain emendations which have added greatly to its value. We can now confidently commend it to the student as a safe and reliable guide to such examinations of the urine as he may be called upon to make." — London Medical Times and Gazette. Mackenzie on Laryngeal Growths. Their History, Causes, Symptoms, Diagnosis, Pathology, Prognosis, and Treatment, with Reports and an Analysis of One Hundred Con- secutive Cases treated by the author, and a Tabular Statement of every published case treated since the invention of the Laryngoscope. By Morell Mackenzie, M.D., Physician to the Hospital for Diseases of the Throat, author of " The Laryngoscope," &c. Illustrated by elegantly executed Chromo's, Lithographic figures, and Wood Engrav- ings. Octavo, Price.........$3.00 Mackenzie on the Laryngoscope in Diseases Of the Throat, with an Appendix on Rhinoscopy, and an Essay on Hoarseness, and Loss of Voice, with additions, by J. Solis Cohen, M. D., Author of " Inhalation, Its Therapeutics and Practice,'" &c. Il- lustrated by two Lithographic Plates, and 51 Engravings on Wood. Price,...........$3.00 "The Use of the Laryngoscope in Diseases of the Throat, and Essays on Growths in the Larynx, are two monographs of first-rate merit. Dr. Mackenzie's Essays would do honor to any place; and he has used the opportunities afforded to diligence and skill to make solid and enduring contributions to science and practice. Both works are, throughout, models of honest and complete work, and are honorable to British medicine, as they are useful to practitioners of every country. The completeness of the clinical records, the abundant graphic illustrations and the .ulness of bibliographical references, are excellent features in both volumes." British Medical Journal. Meigs and Pepper on Children. POUKTH EDITION, ENLAEGED AND IMPEOVED. The publishers have selected the following notice, from a late namber ol the London Lancet, of the New Edition of this work, as indicating, per- haps, more fully than any other of the numerous favorable criticisms that have appeared of it elsewhere, its great value to the Practitioner and Student of Medicine. "'It is not necessary to say much, in the way of criticism, of a work so well known as Meigs on Diseases of Children,' especially when it has reached a fourth edition. Our duty is wellnigh restricted to the point of ascertaining how far, under an old color, it preserves the freshness and the value of a new book — how far it incorpo- rates whac is new with what is old without unseemly marks of mere joining. There is some advantage in starting entirely afresh, in being merely clinical, or in being very short, and limiting one's self to the expression of one's own views and experience. But such is not the nature of this book, and the advantages of it are different. It is a work of more than 900 good American pages, and is more encyclopsedial than clinical. But it is clinical, and withal most effectually brought up to the light, pathological and therapeutical, of the present day. "The book is like so many other good American medical books which we have lately nad occasion to notice; it marvellously combines a risumi of all the best European literature and practice with evidence throughout of good personal judgment, knowl- edge, and experience. It is gratifying to see how our English authors are quoted, and especially how the labors of Hillier, who died so prematurely, are recognized. But the book abounds in exposition of American experience and observation in all that relates to the diseases of children. Not the least interesting additions to the volume are several extensive tables, exhibiting the mortality in Philadelphia of some of the most common and fatal diseases in connection with the variations of the temperature, And prepared with great care from the records of the Board of Health. "The thoroughly fresh nature of the book is especially seen in the care with which eertain articles have been written. Such are those on Rickets and Tuberculosis, Infan- tile Atrophic Paralysis, and Progressive Paralysis. No book now on diseases of chil- dren is complete which does not treat specially of constitutional or diathetic diseases, Buch as rickets and tuberculosis, syphilis, &c. "Among other articles of great interest and value we would mention those on Dis- eases of the Caecum and Appendix Vermiformis, on Indigestion in Children, on Diar- rhoea, on Entero-Colitis, on Intussusception, on Chronic Hydrocephalus, and on Croup and the value of Tracheotomy. "The difficulties of editing a new edition of a medical book of some standing are not more felt in the region of pathology and the classification of disease than in that of therapeutics. In this work this difficulty has been fairly faced by the authors. They have to confess to having changed their practice very materially in the treatment of acute diseases, to having given up mercury in most inflammatory diseases, and almost given up bloodletting. We recommend the views of these authors as to the injurious affects of calomel and antimony to careful consideration. They do not entirely abjure the use of bloodletting in certain cases of pneumonia and meningitis. Indeed, we think they will find reason in future editions to talk a little less freely than they do about bleeding and cupping very young children in certain circumstances of pneumonia, and in certain cases of simple meningitis. With a few exceptions of this kind, the therapeutics are sound and commendable, great importance being given to proper feeding and the general management of infancy and childhood. It is due to authors of so much fairness and experience to publish widely their opinion of the injurious and depressing effects of antimony in the inflammations of children. To infants under two years of age they think it best to give no antimony even in pneumonia. They do lot use tartar emetic at all in the cases of children, but small doses, such as the twelfth of a grain, of the precipitated sulphuret of antimony, every two, three, or four hours, watching its effects, and withdrawing it quickly if symptoms of prostration appear, perhaps without any vomiting. "We are glad to add this work to our library. There are few diseases of children which it does not treat of fully and wisely in the light of the latest physiological, pathological, and therapeutical science." —London Lancet, July 23, 1870. If rice, handsomely bound in Cloth.......$6 00 " " " Leather......7 00 LINDSAY & BLAKIST0N, PUBLISHERS, PHILADELPHIA. No. 5. The Lymphatics or Absorbents. No. 6. The Digestive Organs. No. 7. The Brain and Nerves. No. 8. The Organs of Sense and Voice. No. 9. The Textures. — Microscopic Struc- tures. Marshall's Physiological Diagrams. LIFE-SIZE, AND BEAUTIFULLY COLORED. On account of their large size and the great distinctness of the figures on them, ther« has been a growing demand in this country for these Maps for the Lecture Room and fi.i- lecturing from in Medical as well as other Schools. In order to supply this demand on more favorable terms, we have recently completed an arrangement with the publishers in London, by which we can sell them to the trade and others at a reduced price and on better terms than heretofore. The series, illustrating the whole Human Body, are life-size, each map printed on a Bingle sheet of paper, made specially for the purpose, 7 feel long and 3 feet 9 inches broad, colored in fac-simile of the Original Drawings. There are nine diagrams, as follows- No. 1. The Skeleton and Ligaments. No. 2. The Muscles and Joints, with Ani- mal Mechanics. No. 3. The Viscera in Position. — The Structure of the Lungs. No. 4. The Heart and principal Blood- vessels. Prepared under the direction of John Marshall, F.R.S., F.R.C.S., Pro- fessor of Surgery, University College, and Surgeon to University College Hospital. Price of the Set, Nine Maps, in Sheets, .... $50.00 " handsomely Mounted on Canvas, with Rollers, and Varnished, ..... $80.00 Though designed more especially for purposes of general education, supplying an acknowledged necessity of modern teaching, these diagrams will be found not inappli- cable to the requirements of professed Medical Schools, affording, as they do, a correct preliminary view of the various systems and organs in the human body. For Public School Purposes, for Lectures at Literary, Scientific, and other Institutes, they will be found invaluable; and also to students of Artistic Anatomy, imparting, as they do, when suspended on the walls of the Lecture-hall, School-room, or Studio, a familiar acquaintance with the whole human system. An Explanatory Key to the Physiological Diagrams. By John Marshall, F.R.S., F.R.C.S., &c. Octavo. Paper covers..........50 cts. Description of the Human Body. Its Structure and Functions. Illustrated by Physiological Diagrams, Designed for the Use of Teachers in Schools and Young Men destined for the Medical Profession, and for popular Instruction generally. New Edition. By John Marshall, F.R.S., F.R.C.S., Professor of Surgery, University College, and Surgeon to the University College Hospital. The work contains 260 quarto pages of Text, bound in cloth, and 193 Colored Illustrations, arranged in Nine Folio Diagrams, carefully colored and reduced from Proj'. Marshall's large work. 2 vols. Cloth. . §10.00 Murphy's Review of Chemistry for Students. Adapted to the Courses as Taught in the Principal Medical Schools in the United States. By John G. Murphy, M.D. . . . $1.25 LINDSAY AND BLAKISTON'S PUBLICATIONS. Meadows' Manual of Midwifery, a New Text-Book Including the Signs and Symptoms of Pregnancy, Obstetric Operations, Diseases of the Puerperal State, &c, &c. By Alfred Me/dows, M.D., Member of the Royal College of Physicians, &c, &c. First American from the Second London Edition. With numerous Illustra- tions. Price,.........$3.00 "Those who read the first edition of this work will bear us out in thinking that Dr. Meadows's Manual forms one of the most convenient, practical, and concise books yet published on the subject. It was espe- cially good as a student's manual, and the author has, in his second edition, sought to make it of equal value to the practitioner. The part which treats of obstetric operations has been well revised, and has received numerous additions, and the several chapters on Unnatural and Complex Labors likewise comprise much new matter. Upwards of ninety new engravings have been inserted in this edition, and, with a view to facilitate reference, the author has furnished it with a very full and complete table of contents and index. We can cordially recommend this manual as accurate and practical, and as containing in a small compass a large amount of the kind of information suitable alike to the student and practitioner."—London Lancet, May 6,1871. " This new edition of a book which was at once recognized as a good manual, is a considerable improve- ment on its predecessor. It is eminently a book which will teach the student. . . . Not merely is the prac- tical treatment of Labor, and also of the Diseases and Accidents of Pregnancy, well and clearly taught, but the anatomical machinery of parturition is more effectively explained than in any other treatise that we remember; and besides this, the book is honorably distinguished among manuals of Midwifery by the ful- ness with which it goes into the subject of the structure and development of the ovum. Dr. Meadows has done good service in giving a clear account of this subject in a very short space, yet with sufficient fulness. On all questions of treatment, whether by medicines, by hygienic regimen, or by mechanical or operative appliances, this treatise is as satisfactory as a work of manual size could be; and altogether, students and practitioners can hardly do better than adopt it as their vade-mecum." — The Practitioner. Maxson's Practice of Medicine. By Edwin R. Maxson, M.D., formerly Lecturer on the Practice of Medicine in the Geneva Medical College, &c. . . $4.00 Morris on Scarlet Fever. Its Pathology and Therapeutics. By Casper Morris, M.D., Fellow of the College of Physicians of Philadelphia, &c. . . . $1.50 Mendenhall's Medical Student's Vade Mecum. A Compendium of Anatomy, Physiology, Chemistry, the Practice of Medicine, Surgery, Obstetrics, Diseases of the Skin, Materia Medica, Pharmacy, Poisons, &c, &c. By George Mendenhall, M.D., Pro- fessor of Obstetrics in the Medical College of Ohio, &c, &c. Tenth Edition, Revised and Enlarged, with 224 Illustrations. . $2.50 Pennsylvania Hospital Reports. Edited by a con- mittee of the Hospital Staff, J. M. DaCosta, M.D., and William Hunt, M.D. Vols. 1 and 2, for 1868 and 1869, each volume contain- ing upwards of Twenty Original Articles, by former and present Members of the Staff, now eminent in the Profession, with Litho- graphic and other Illustrations. Price per volume, . $4.00 At last, however, the work has been commenced, the Philadelphia Physicians being the first to occupy this field of usefulness. The first Reports were so favorably re- ceived, on both sides of the Atlantic, that it is hardly necessary to speak for them the universal welcome of which they are deserving. The papers are all valuable contri butions to the literature of medicine, reflecting great credit upon their authors. The work is one of which the Pennsylvania Hospital may well be proud. It will do much teward elevating the profession of this country. — American Journal of Obstetrics. LINDSAY AND BLAKISTON'S PUBLICATIONS. Pereira's Physician's Prescription Book. Containing Lists of Terms, Phrases, Contractions, and Abbreviations, used in Prescriptions, with Explanatory Notes, the Grammatical Constructions of Prescriptions, Rules for the Pronunciation of Pharmaceutical Terms, A Prosodiacal Vocabulary of the Names of Drugs, etc., and a series of Abbreviated Prescriptions illustrating the use of the preceding terms, etc.; to which is added a Key, containing the Prescriptions in an unabbreviated Form, with a Literal Translation, intended for the use of Medical and Pharmaceutical Students. By Jonathan Pereira, M.D., F.R.S., etc. From the Fifteenth London Edition. Price, in cloth,........$1.25 " in leather, with Tucks and Pocket, . . . 1.50 This lit+le work has passed through fifteen editions in London and several in this country. The present edition of which this is a reprint has been carefully revised and many additions made to it. Its great value is proven both by its large sale and the many favorable notices of it in the Medical Press. Paget's Surgical Pathology. Third London Edition. Lectures delivered at the Royal College of Surgeons of England, by James Paget, F.R.S., Surgeon to St. Bartholomew's Hospital, &c, &c. Third London Edition, edited and Revised by William Turner, M.D., Lond. Professor of Anatomy in the University of Edinburgh, &c. One volume, Octavo, with numerous Illustrations. Price, .... $7.50 A new and revised edition of Mr. Paget's Classical Lectures on Surgical Pathology needs no introduction to our readers. Commendation of it would be as superfluous as criticism would be out of place. Suffice it to say that almost every page bears evidence that the present edition has been, as the author mentions in his preface, " carefully re- vised," from a clinical point of view by himself, and from the pathological by his only less distinguished editor, Professor Turner. The latest observations of pathologists in all parts of the world have received due attention, and, as a consequence, the lectures in their present shape are not only, as Mr. Paget modestly hopes they may be con- sidered, "better than they were," but probably the very best to which the student of pathology can resort. — American Medical Journal. Prince's Plastic and Orthopedic Surgery. Containing, 1. A Report on the Condition of, and Advances made in, Plastic and Orthopedic Surgery up to the Year 1871. 2. A New Classification and Brief Exposition of Plastic Surgery. With numerous Illustrations. 3. ORTHorEDics: A Systematic Work upon the Prevention and Cure of Deformities. With numerous Illustrations. In one volume, Octavo. Price,......$4.50 "This is a good book, upon an important practical subject; carefully written. abundantly illustrated, and well printed. It goes over the whole ground of deformi- ties of all degrees — from cleft-palate and club-foot, to spinal curvatures and ununited fractures. It appears, moreover, to be an original book, so far as one chiefly of com- pilation can be so. Such a book was wanted, and it deserves success." — Med. and Surg. Reporter. Rindfleisch's Text-Book of Pathological Histology. 208 Illustrations. An Introduction to the Study of Pathological Anatomy. By Dr. Edward Rindfleisch, 0. 0. Professor of Pathological Anatomy in Bonn. Translated from the Second German, Edition, by Wm. C. Kloman, M. D., assisted by F. T. Miles, M. D., Professor of Anatomy, Uni- versity of Maryland, &c, &c. CONTENTS. Introduction, Author's and Editor's Prefaces. General Part. 1. Decomposition and Degeneration of Tissues. 2. Pathological New Formations. Special Part. 1. Anomalies of the Blood and the Places of its Formation, especially of the Spleen and Lymphatic Glands. 2. Anomalies of the Circulatory Appa- ratus. 3. Anomalies of Serous Membranes. 4. " the Skin. 6. " Mucous Membranes. 6. " the Lung. 7. " " Liver. 8. " " Kidney. Index and Bibliography. Containing 208 Elaborately Executed Microscopical Illustrations. One volume, octavo. Price, cloth, $6.00; sheep, $7.00. Prof. Rindfleisch's Text-Book of Pathological Histology, so justly celebrated in Germany, where it is considered the most complete and thorough work of its kind, having passed rapidly to a second edition, is also very highly valued and commended by German Medical scholars in this country, many of whom are not only familiar with the book, but with the author's great reputation as a teacher and professor of this branch of medical study. The translators are both gentlemen who by their past education have been peculiarly fitted for the task of translating the work. Dr. Kloman from early life has been familiar with the German language, while Prof. Miles has made the subject one of special study, both gentlemen being also practical microscopists. The Publishers therefore offer a translation of this truly valuable work to the Medical Profession in the United States, feeling the utmost confidence that in both manner and style it will prove acceptable to them. In their Preface, the Translators say: "In presenting the English reading portion of the Medical Profession with a translation of the valuable work of Prof. Rindfleisch, the translators scarcely deem an apology necessary. The merits of the book itself, and the fact that it fills an unoccupied gap in our most recent literature upon the subject of Pathological Histology, was judged to be an ample in- centive for undertaking the labor of the translation. The work of Virchow translated by Chance, is, in many points, antiquated, and the more recent work of Bilbroth, translated by Hackley, occupies the ground but partially, and is professedly a work of Surgical Pathology." This book is translated and published in this country by special arrangement with the author. 9. Anomalies of the Ovaries. 10. (< " Testicles. 11. <« " Mammae. 12. u " Prostate Gland. 13. (( " Salivary Glands. 14. (( " Thyroid Gland. 15. (« " Suprarenal Cap sules. 16. «« " Osseous System. 17. (I " Nervous System. 18. l« " Muscular System. LINDSAY AND BLAKISTON'S PUBLICATIONS. Radcliffe's Lectures on Epilepsy, Pain, Pa- ralysis, And certain other Disorders of the Nervous System. By Charles Bland Radcliffe, M.D., Fellow of the Royal College of Physicians of London, &c, &c. With Illustrations. . . . . $2.00 "The reputation which Dr. Radcliffe possesses as a very able authority on nervous affections, will commend his work to every medical practitioner. We recommend it as a work that will throw much light upon the Physiology and Pathology of the Nervous System." — Canada Medical Journal Robertson's Manual on Extracting Teeth. Founded on the Anatomy of the Parts involved in the Operation; the Kinds and Proper Construction of the Instruments to be used; the Accidents liable to occur from the Operation, and the Proper Reme- dies. By Abraham Robertson, D.D.S., M.D. Second Edition, Revised and Improved. With Illustrations. . . $1.50 Rihl & O'Conner's Physician's Diary, Monthly, Semi-Annual, and Annual Journal and Cash-Book Combined, The Fourth Revised Edition. A large folio volume, with printed Heads, Index, &c, &c. Bound in full leather. Price, . . $1.50 Back Volumes or Numbers furnished. Renouard's History of Medicine. From its Origin to the Nineteenth Century. With an Appendix contain- ing a Philosophical and Historical Review of Medicine to the present time. By P. V. Renouard, M.D. Translated from the French by Cornelius G. Comegys, M.D., Professor of the Institutes of Medicine in the Medical College of Ohio, &c. Octavo. Price, . $4.00 Reports on the Progress of Medicine and Surgery. Including Physiology, Practical Medicine, Surgery, Ophthalmic Medi- cine, Midwifery, Diseases of Women and Children, Materia Medica, Medical Jurisprudence, and Public Health. Edited by Drs. Power, Holmes, Ainstie, Barnes, Windsor, &c, &c, under the patronage and direction of the Sydenham Society of London. One volume. Octavo. Price,.........$2.00 Ryan's Philosophy of Marriage. In its Social, Moral, and Physical Relations, with an Account of the Dis- eases of the Genito-Urinary Organs. The Physiology of Generation in the Animal and Vegetable Kingdoms, &c, &c. By Michael Ryan, M.D., Member of the Royal College of Physicians and Sur- geons in London, &c. 12mo. ...... $1.00 fteese's American Medical Formulary. $1.50 LINDSAY AND BLAKISTON'S PUBLICATIONS. Reynolds's Lectures on the Clinical Uses of Electricity, delivered at the University College Hospital. By J. Russell Reynolds, M.D., F.R.S., Professorofthe Principles and Practice of Medicine, University College, London, editor of " A System of Medi- cine," &c, &c. One volume. Post octavo. Price, . . $1.50 Reese's Analysis of Physiology. Price. . $1.50 Stille's Epidemic Meningitis; Or, Cerebro-Spinal Meningitis. By Alfred Stille, M.D., Professor of the Theory and Practice of Medicine in the University of Pennsylva- nia, &c, &c. In one volume, Octavo, . . . . $2.00 " This monograph is a timely publication, comprehensive in its scope, and present- ing within a small compass a fair digest of our existing knowledge of the disease, par- ticularly acceptable at the present time. It is just such a one as is needed, and may be taken as a model for similar works."—Am. Journal Med. Sciences. Stille's Elements of General Pathology. A Practical Treatise on the Causes, Forms, Symptoms, and Results of Disease. Second Edition preparing. Sweringen's Pharmaceutical Dictionary. A Pharmaceutical Lexicon or Dictionary of Pharmaceutical Science, containing a Concise Explanation of the various Subjects and Terms of Pharmacy, with Collateral Selections from the Kindred Sciences ; also Formulae for Officinal, Empirical, and Dietetic Preparations, Antidotes to Poisons, &c, &c. By Hiram V. Sweringen, Member of the American Pharmaceutical Association, &c, &c. In preparation. Sansom on Chloroform. Its Action and Administration. By Arthur Ernest Sansom, M.B., Physician to King's College Hospital, &c, &c. 12mo. . $2.00 " The work of Dr. Sansom may be characterized as most excellent. Written not alone from a theoretical point of view, but showing very considerable experimental study, and an intimate clinical acquaintance with the administration of these remedies, — passing concisely over the whole ground, giving the latest information upon every point, — it is just the work for the student and practitioner."—Amer. Medical Journal. Scanzoni on Women. A Practical Treatise on the Diseases of the Sexual Organs of Women. Translated from the French. By A. K. Gardner, A.M., M.D., &c. With Illustrations. Octavo,......$5.00 Stokes on the Diseases of the Heart And the Aorta. By William Stokes, Regius Professor of Physic in the University of Dublin; Author of the Diseases of the Chest, &c, &c. Second American Edition. Octavo, .... $3.00 THOMAS HAWKES TANNER'S WORKS. " The leading feature of Dr. Tanner's books is their essentially practical character." London Lancet. The Practice of Medicine, just ready. FIFTH AMERICAN, FROM THE SIXTH LONDON EDITION. Revised, much Enlarged, and thoroughly brought up to the present time. With a complete Section on the Diseases Peculiar to Women added; also an extensive Appendix of Formuloz for Medicines, Baths, Mineral Waters, Climates, &c. By Thomas Hawkes Tanner, M.D., Fellow of the Royal College of Physicians, &c. One Volume. Royal Octavo, containing over 1100 pages. Price, handsomely bound in Cloth, . . $6.00 Leather, . $7.00 There is a common character about the writings of Dr. Tanner — a character which constitutes one of their chief values: they are all essentially and thoroughly practi- cal. Dr. Tanner never, for one moment, allows this utilitarian end to escape bis mental view. He aims at teaching how to recognize and how to cure disease, and in this he is thoroughly successful. ... It is, indeed, a wonderful mine of knowledge.—Medical Times. Dr. Tanner has always shown in his writings that he possesses a peculiar faculty of committing to print just that kind of information which the practitioner most needs in everyday practice, and of rejecting useless theories or hypothetical statements.—Lancet. The author has, in the manner in which he has dealt with the subject, given another evidence of that happy facility which he possesses of giving the essential points of a mass of information in a well connected and instructive form.—Brit. Med. Journ. The student will find the work the best text-book on the practice of medicine, while the practitioner will possess in it a thoroughly safe guide at the bedside. —Dub. Med. Quarterly. Tanner's Practical Treatise on the Diseases of Infancy and Childhood, price, $3.50. THIRD AMERICAN EDITION, REVISED AND ENLARGED. By Alfred Meadows, M.D., London, M.R.C.P., Physician to the Hospi- tal for Women and to the General Lying-in Hospital, &c, &c. " This book of Dr. Ta'nner's has been much enlarged and the plan altered by Dr. Meadows. As it now stands it is probably one of the most complete in our language. It no longer deals with children's diseases only, but includes the peculiar conditions of childhood, both normal and abnormal, as well as the therapeutics specially appli- cable to that class of patients. The articles on Skin Diseases have been revised by Dr. Tilbury Fox, and those on Diseases of the Eye by Dr. Brudenell Carter, both gentlemen distinguished in these specialties."—Medical Times and Gazette. Tanner's Index of Diseases and their Treatment. With upwards of 500 Formulae for Medicines, Barns, Mineral Waters, Climates for Invalids, &c., &c. Octavo. . . $3.00 To the busy practitioner it must be an advantage to see at a glance on a quarter or half a page the principal point in any disease about which he may wish to L.vve hia memory refreshed or his mind stimulated. It will be found a most valuable companion to the judicious practitioner. — The Lancet. Tanner's Memoranda of Poisons. Frcm the Second London Edition......50 eta. LINDSAY AND BLAKISTON'S PUBLICATIONS. Tilt's Change of Life In Health and Disease. A Practical Treatise on the Nervous and other Affections incidental to Women at the Decline of Life. By Edward John Tilt, M.D. From the Third London Edition. In one volume. Octavo, ........ $3.00 The work is rich in personal experience and observation, as well as in ready and sensible reflection on the experience and observation of others. The book is one that no practitioner should be without, as the best we have on a class of diseases that makes a constant demand upon our care, and requires very judicious management on the part of the practitioner. — London Lancet. The great abilities of Dr. Tilt, his extensive knowledge, and his literary power are well shown in this book, and we are pleased to say that it has substantial and peculiar merits. It contains many sage, practical recommendations, and will amply repay perusal. — Edinburgh Medical Journal. Dr. Tilt has been a very earnest and a very faithful worker in the physiology and diseases of women, and has made contributions to the literature of the subject which are all of accepted value. — British Medical Journal. Tyler Smith's Obstetrics. A Course of Lectures. By W. Tyler Smith, M.D., Physician, Ac' coucheur, and Lecturer on Midwifery, &c. Edited by A. K. Gard- ner, M.D. With Illustrations. Octavo, .... $5.00 Toynbee on Diseases of the Ear. Their Nature, Diagnosis, and Treatment. A new London Edition, with a Supplement. By James Hinton, Aural Surgeon to Guy's Hospi- tal, &c. With Illustrations. Octavo, .... $5.00 Thompson's Clinical Lectures on Pulmonary Consumption, octavo, .... $2.00 Tyson's Cell Doctrine: Its History and Present State, with a Copious Bibliography of the Sub- ject, for the use of Students of Medicine and Dentistry. By James Tyson, M.D., Lecturer on. Microscopy in the University of Pennsyl- vania, &c, &c. With a Colored Plate, and numerous Illustrations on Wood. Price,........$2.00 Dr. Tyson furnishes in this work a concise and instructive resume of the origin and advance of the doctrine of Cell Evolution. In it we find the theories of Virchow, Robin, Huxley, Hughes, Bennett, Beale, and other distinguished men. Its pages contain what could otherwise only be learned by the perusal of many works, and they supply the reader with a continuous, complete, and general knowledge of the history, progress, and peculiar phases of the Cell Doctrine, accompanied by careful references and a copious bibliography. Virchow's Cellular Pathology. Translated from the Second Edition. By Frank Chance, B.A., M.A., &c. With Notes and Emendations, and 144 Engravings. 8vo. $5.00 Trousseau's Clinical Lectures. VOL. IV., COMPLETING THE WORK, NOW READY. Price $4.00 Lectures on Clinical Medicine, delivered at the Hotel-dieu, Paris. By A. Trousseau, Professor of Clinical Medicine in the Faculty of Medi- cine, Par in, &c, &c. Trousseau's Lectures on Clinical Medicine, so favorably received, as well by the profession of the United States as abroad, are published in this country in connection with the New Sydenham Society, under whose auspices the translation of Vols. II. and III. have been made. Either of these volumes can be furnished separately, and in order to still further extend the circulation of so valuable a work, the Publishers have now reduced the price to Five Dollars per volume. Contents of Volume 1. —Translated and Edited by P. Victor Bazire, M. D., $c— Lecture 1. On Venesection in Cerebral Haemorrhage and Apoplexy. 2. On Apoplec- tiform Cerebral Congestion, and its Relations to Epilepsy and Eclampsia. 3. On Epilepsy. 4. On Epileptiform Neuralgia. 5. On Glosso-laryngeal Paralysis. 6. Pro- gressive Locomotor Ataxy. 7. On Aphasia. 8. Progressive Muscular Atrophy. 9. Facial Paralysis, or Bell's Paralysis. 10. Cross-paralysis, or Alternate Hemiplegia. 11. Infantile Convulsions. 12. Eclampsia of Pregnant and Parturient Women. 13. On Tetany. 14. On Chorea. 15. Senile Trembling and Paralysis Agitans. 16. Ce- rebral Fever. 17. On Neuralgia. 18. Cerebral Rheumatism. 19. Exophthalmio Goitre, or Graves' Disease. 20. Angina Pectoris. 21. Asthma. 22. H joping Cough. 23. On Hydrophobia. Contents of Volume II.— Translated from the Edition of 1868 {being the last revised and enlarged edition), by John Rose Cormack, M. D., Edin., F.R.S.E, $c. —Lecture 1. Small-pox. 2. Variolous Inoculation. 3. Cow-pox. 4. Chicken-pox. 5. Scarlatina. 6. Measles, and in particular its unfavorable Symptoms and Complications. 7. Rubeola. 8. Erythema Nodosum. 9. Erythema Papulatum. 10. Erysipelas, and in particular Erysipelas of the Face. 11. Mumps. 12. Urticaria. 13. Zona, or Herpes Zoster. 14. Sudoral Exanthemata. 15. Dothinenteria, or Typhoid Fever. 16. Typhus. 17. Membranous Sore Throat, and in particular Herpes of the Pharynx. 18. Gangrenous Sore Throat. 19. Inflammatory Sore Throat. 20. Diphtheria. 21. Thrush. Contents of Volume III.—Translated from the Edition of 1868, by John Rose Cormack, M.D., Edui., F.R.S E., §c.—Lecture 22. Specific Element in Disease. 23. Contagion. 24. Oztena. 25. Stridulous Laryngitis, or False Croup. 26 Qidema of the Larynx. 27. Aphonia: Cauterization of the Larynx. 28. Dilatation of the Bronchi and Bron- chorrhooa. 29. Hemoptysis. 30. Pulmonary Phthisis. 31. Gangrene of the Lung. 32. Pleurisy: Paracentesis of the Chest. 33. Traumatic Effusion of Blood into the Pleura: Paracentesis of the Chest. 34. Hydatids of the Lung. 35. Pulmonary Abscesses and Peripneumonic Vomicoe. 36. Treatment of Pneumonia. 37. Paracen- tesis of the Pericardium. 38. Organic Affections of the Heart. 52. Alcoholism. 62. Spermatorrhoea. 63. Nocturnal Incontinence of Urine. 64. Glucosuria: Saccharine Diabetes. 65. Polydipsia. 67. Vertigo a Stomacho Lasso. 4 Volumes Octavo. Vols. 1, 2, and 3, Price 35.00 each ; Vol. 4, Price $4.00. OPINIONS OF THE PRESS. " Trousseau furnishes us with an example of the best kind of Clinical teaching. It. ia a book that deserves to be popularized. The translation is perfect." — Medical Timet and Gazette. "The oreat reputation of Prof. Trousseau as a practitioner and teacher of Medicine in all its branches, renders the present appearance of his Clinical Lectures particularly welcome." — Medical Press and Circular. "The publication of Trousseau's Lectures will furnish us with one of the very best practical treatises on disease as seen at the bedside." — British and Foreign Medico- Chirurgical Review. " A clever translation of Prof. Trousseau's admirable and exhaustive work, the best book of reference upon the Practice of Medicine."—Indian Medical Gazette. 'The Lectures of Trousseau, in attractiveness of manner and richness of thoroughly practical matter, worthily takes a place beside the classical lectures of Watson and Graves." — British Medical Journal. "Trousseau is essentially the French Graves, and his lectures should sooner than ihia have been translated into English." — Lancet. LINDSAY AND BLAKISTON'S PUBLICATIONS. Wythes' Physician's Pocket, Dose,and Symp- tom Book. THE TENTH EDITION. Containing the Doses and Uses of all the Principal Articles of the Materia Medica, and Original Preparations; A Table of Weights and Mea- sures, Rules to Proportion the Doses of Medicines, Common Abbre- viations used in Writing Prescriptions, Table of Poisons and Antidotes, Classification of the Materia Medica, Dietetic Preparations, Table of Symptomatology, Outlines of General Pathology and Therapeutics, &c. By Joseph H. Wythes, A.M., M.D., &c. The Tenth Revised Edition, Price, in cloth,........$1.25 " leather, tucks, with pockets, ... 1.50 This little manual has been received with much favor, and a large number of copies Bold. It was compiled for the assistance of students, and to furnish a vade mecum for the general practitioner, which would save the trouble of reference to larger and more elaborate works. The present edition has undergone a careful revision. The thera- peutical arrangement of the Materia Medica has been added to it, together with such other improvements as it was thought might prove of value to the wor«. Williams on Consumption, london edition. Pulmonary Consumption; Its Nature, Varieties, and Treatment. With an Analysis of One Thousand Cases to exemplify its duration. By C. J. B. Williams, M.D., F.R.S., author of Williams' Principles of Medicine, Senior Consulting Physician to the Hospital for Con- sumption, &c. &c, and Charles Theodore Williams, M.D., Physi- cian to the Hospital for Consumption. Brompton. Demy Octavo. Price>...........$3.00 This edition of Williams on Consumption is issued in the United States by special arrangement with the London publishers. It is the Author's Edition, printed in London under his supervision, on fine paper and large clear type, and is offered at a much less rate than under ordinary circumstances it could be imported and sold at. "For the last forty years, Dr. Williams has been studying and treating Tubercular Diseases, and if he has had to modify much of his teaching, and more of his treatment, he can still speak from a more enormous experience, and a closer study of the morbid processes involved in tuberculosis, than most living men, and he can look backwards and forwards with as much satisfaction as most of his contemporaries." — London Lancet. Walker on Intermarriage. Or, the Mode in which, and the Causes why, Beauty, Health, and Intellect result from certain Unions, and Deformity, Disease, and Insanity from others. With Illustrations. By Alexander Walker, Auinor of " Woman,'1 " Beauty," &c, dec. 12mo.....$]_ 50 LINDSAY AND BLAKISTON'S PUBLICATIONS. Walton's Operative Ophthalmic Surgery. By Haynes Walton, F.R.C.S., Surgeon to the Central London Ophthal- mic Hospital, &c. With 169 Illustrations. Edited by S. Litiell, M.D., Surgeon to the Wills Hospital for the Diseases of the Eye, &c. Octavo...........$4.00 " It is eminently a practical work, evincing in its author great research, a thorough knowledge of his sub- ject, and an accurate and most observing mind." —Dublin Quarterly Journal. Watson's Practice abridged. A Synopsis of the Lectures on the Principles and Practice of Physic. De- livered at King's College, London, by Thomas Watson, M.D., Fellow of the Royal College of Physicians, &c, &c. From the last London Edition. With a concise but Complete Account of the Properties, Uses, Preparations, Doses, &c, of all the Medicines mentioned in these Lectures, and other Valuable Additions, by J. J. Meylor, A.M., M.D., &c, &c. A neat locket Volume bound in cloth flexible. . . . $2.00 Wells' Treatise on the Diseases of the Eye, illustrated by Ophthalmoscopic Plates and Numerous Engravings on Wood. By J. SffiLBERG Wells, Ophthalmic Surgeon to King's College Hospital, &c. Second London Edition, cloth, $6.50; leather, $T50. This is the author's own edition, printed in London under his supervision, and issued in this country by special arrangement with him. Wright on Headaches. Their Causes and their Cure. By Henry G. Wright, M.D., Member of the Royal College of Physicians, &c. &c. From the Fourth London Edition. 12mo. Cloth........$1.25 " Few affections are more unmanageable and more troublesome than those of which this essay treats; and we doubt not that any suggestions by which we can relieve them will be gladly received by physicians. The author's plan is simple and practical. He treats of headaches in childhood and youth, in adult life and old age, giving in each their varieties and symptoms, and their causes and treatment. It is a most satis- factory monograph, as the mere fact that this is a reprint of the fourth edition, testifies. "The great pains which the author takes to clear up the differential diagnosis of the different varieties, and establish a satisfactory basis for rational treatment, are every- where visible. While such a valuable fund of information is offered to the practitioner at the cost of a single visit, he should not let his patient suffer for want of it." - ■ Medical and Surgical Reporter. Wells on Long, Short, and Weak Sight, and their Treatment by the Scientific Use of Spectacles. Third Edition Re- vised, with Additions and Numerous Illustrations. By J. S