DISEASES OF THE THROAT.

REPORT OF DISEASES OF THE THROAT.

F. I. Knight, M.D. Harv.

Laryngotomy for the Removal of Neo-plasms (Krishaber, Planchon, Guyon, Cut-ter, Schwebel, Luschka). —A distinguishedGerman laryngoscopist who has had muchexperience in the removal of neoplasmsfrom the larynx, recently remarked that hehad never performed laryngotomy for thispurpose, because he had never had a casein which it was necessary in order to re-move the growT th. Still, there are cases inwhich it undoubtedly may be necessary onaccount ofthe situation of the growth (e.g.,in the ventricle of Morgagni), the age ofthe patient, or some other peculiarity ofthe case. His remark, however, shows the'great improvements which have been madein the methods of operating per vias natu-rales.

We wish, however, in thepresent article,to lay before our readers some account ofthe improved methods of laryngotomy, whenthis operation is necessary. Until the ap-pearance of Krishaber’s article (Diction-naire Encyclopedique des Sciences Medi-cates, 1868), no general laws in regard tothe limitation of the operation had been laiddown for the guidance of the surgeon. Inthis excellent article, M. Krishaber says:“ We have just seen, in considering the

two dominant symptoms, that the polypof the larynx being diagnosticated, the sur-geon, according to the nature of the symp-toms which it establishes, should make,sometimes, direct laryngotomy, sometimesthis operation preceded by tracheotomy ;

and ought sometimes, on the contrary, tooperate per vias naturales.” “ When thepolyp is voluminous and, situated in thecavity of the larynx, is liable to causeasphyxia, it is necessary to perform tra-cheotomy. If the polyp is multiple, if itsextraction per vias naturales encounters dif-ficulties pertaining to the age or particularcondition of the patient, if the nature, even,of the polyp causes a fear that a partial re-moval may cause a rapid multiplication, inall these cases the polyp shouldbe extract-ed per vias artifidales. When, on the con-

trary, the polyp is situatedhigh (at the tip of the epiglottis, for in-stance) to permit it to be seen directly, orwhen, with the laryngoscope, it is disco-vered in the cavity of the larynx, if itsvolume occasions slight dyspnoea, if it isimplanted in such a manner that its dis-placement cannot lead to an unforeseen ac-cess of asphyxia ; if, in a word, it is possi-ble to prepare the patient, the operationwill be performed per vias naturales

Per vias Aetificiales.“Laryngotomy in cases of polyp of the

larynx has hitherto been made very rarely.The proceedings employed are thus classi-fied :

a. Section ofall the parts of the larynx(cricoid, thyroid, the membrane whichunites them and the thyro-hyoid mem-brane), plus some rings of the tra-chea. (Ehrmann, Gordon Buck, Gibb,Boeckel).

b. Same operation without section of thecricoid (Debron).

c. Section of the thyroid alone (Brauers,ofLouvain).

d. Section of the thyroid and of the thyro-hyoid membrane (Busch, Koeberle).

e. Section of the cricoid and trachea(Gilewsky).

f. Section of the thyro-hyoid membranealone (Pratt, Follin). ;?

From a consideration of the cases referredto above, M. Krishaber draws the follow-ing inferences, which, on account of thelimited number of cases, diversity of theoperations and multiple conditions, he doesnot claim to be conclusive.

“ 1. There are cases where destructionat their seat and removal of polyps of thelarynx are impossible per vias naturales,perhaps on account of their volume, per-haps for very many otherreasons which wehave developed at length.

2. In these cases, two operative proceed-ings may be employed:

2

a. Sub-thyroid laryngotomy, that is tosay the section of the thyro-hyoid mem-brane, in case of multiple vegetation,as these have a tendency to recur (pa-pillomata) and as their seat docs notextend below the vocal cords.

b. Sub-cricoid laryngotomy, that is tosay the section of the tracheo-cricoidmembrane, plus the section of some ofthe rings of the trachea, when thepolyp is inserted below the vocal cords.

3. The section of the cricoid ought neverto be practised, whatever may be the seatand volume of the tumor, this being alwaysaccessible by the proceedings above or be-low which we have just indicated.

4, The section of the thyroid may benecessary, if the tumor is situated in theventricle of Morgagni, but in this casealone. This section ought to be avoidedunder all other circumstances :

a. Because the penetrating wounds ofthe thyroid produce, necessarily, lesionof the vocal cords, however exactly inthe median line of the cartilage theoperation may be performed.

b. Because the wounds of the cartilages-of the larynx (and what we say herehas reference, also, to the cricoid) mayproduce perichondritis and consecu-tive caries.

c. Because these cartilages are quite of-ten ossified; because this ossificationis ordinarily premature in individualsafflicted by diseases of the larynx, andbecause it is necessarily a cause ofmore difficult cicatrization.

d. And because, in fact, all the surfaceof the cavity of the larynx is accessi-ble to the sight and to the touch, with-out the section of any of the cartilagesof the larynx.

5. In cases where asphyxia is imminent,tracheotomy will find its immediate in-dication, and the safety of the patientonce reestablished by this operation, thesurgeon will consider the consecutiveproceedings which he should employfollowing the indications that we havedeveloped in detail.”

Dr. Charles Planchon ( Fails Gliniques deLaryngofomie, Paris, 1869) adopts M. Krish-aber’s classification of operations with someextension as follows :

“I. Laryngotomy direct, comprising :a. Section of the thyroid cartilage alone.b. Section of the thyroid cartilage and

of the thyro-hyoid membrane.c. Section 0f the thyroid cartilage and of

the crico-thyroid membrane.

d. Section of the thyroid cartilage andof the thyro-hyoid and crico-thyroidmembranes.

e. Section of the thyroid cartilage, of thethyro-hyoid, crico-thyroid membranes,and of the cricoid cartilage.

f. Section of the thyroid cartilage, of thecrico-thyroid, tracheo-cricoid mem-branes, of the cricoid, and of the firstrings of the trachea.

g. Section of the thyroid cartilage, of thethyro-hyoid, crico-thyroid membranes,of the cricoid, and of the first rings ofthe trachea.

2. Laryngotomy indirect, comprising:—a. Horizontal section of the thyro-hyoid

membrane.b. Horizontal section of the crico-thyroid

membrane.c. Horizontal section of the tracheo-cri-

coid membrane.d. Section of the cricoid and of the first

rings of the trachea.”M. Planchon then introduces, in detail,

the cases which have come to his know-ledge where laryngotomy has been perform-ed according to one or another of thesemethods, either for removal of a neoplasmor a foreign body, and from a considerationof these cases draws the following con-clusions :

“1. The artificial opening of the larynxhas been made by two different proceed-ings :

a. Laryngotomy, direct: section of thethyroid cartilage.

b. Laryngotomy, indirect: section of thethyro-hyoid, crico-thyroid, or tracheo-cricoid membranes,

2. These operations ought to be practis-ed independently, except in case of lesionsextraordinarily extensive.

3. Tracheotomy will only be performedwith laryngotomy when there are specialindications.

4. The section of the cricoid cartilageought always to be avoided.

5. The choice of the operation will beestablished by the exact diagnosis of thelesion.

6. The section of the thyroid cartilage isnot serious as regards life; practised me-thodically, it is not serious for phonation.The ossification of this cartilage is not acontra-indication. The healing will onlybe slower. This operation may be madeevery time there is need of access into thecavity, proper, of the larynx. The newartificial passage can be augmented at willby the section of the conoid ligament and

3of the crico-thyroid membrane, practisedtransversely perhaps to the right, perhapsto the left of the median line, perhaps ontwo sides at once. In certain cases of se-rious fracture of the larynx, thyroid laryn-gotomy should be made in preference totracheotomy. It might be very useful insome cases of obliteration of the larynxconsecutive to wounds of the respiratorytube, or certain grave affections of theorgan.

7. Indirect laryngotomy should only beemployed in very special cases. The pro-ceeding employed by Follin—section ofthe thyro-hyoid membrane immediatelyabove the thyroid cartilage—is preferableto the proceeding of Malgaigne, sectionbelow the hyoid bone.

8. Section of the crico-thyroid membrane,and that of the tracheo-cricoid membrane,are very simple operations, but still morerarely applicable than the preceding. 7 ’

M. Krishaber (La Thyrotomie Restreinteappliquee au polype du ventricule du la-rynx, Paris, 1869) gives a resume of a paperpresented to the “ Societe Imperiale de Chi-rurgie,” in which he recommends sectionof the thyroid cartilage without section ofany of the membranes, and containing thedetails of a case and the following conclu-sions derived from his farther experience :

"1. There are cases of polyp of thelarynx, in which destruction and extirpa-tion per vias naturales are impossible; inthese cases, one can open the larynx direct-ly, obtain its complete cicatrization and thecure of the patient.

“2. The choice of the mode of operationwill depend upon the tumor and its struc-ture ; the opening of the larynx can beperformed on the membranes of the larynxor on one of its cartilages.

“3. In cases where the polyp is implant-ed in the ventriculeof Morgagni, section ofthe thyroid cartilage must be made. Theseparation thus obtained is sufficient forthe extraction of even a voluminouspolyp,without section of the thyro-hyoid andcrico-thyroid membranes. The section ofthis cartilage can be made so as to sparethe vocal cords, and then the voice remainsintact. The presumed ossification of thecartilage is not a contra-indication althoughit retards cicatrization.

“ 4. Laryngotomy which consists in thesection of the entire larynx, membranesand cartilages, such as has been performeda number of times, ought to be rejected.When, by means of the larynscope theexact seat of the tumor is established, it is

sufficient to open the larynx at this exactseat.

“5. Of all the methods employed up tothis time for the extraction of polyps, theoperation, of which I have just given thehistory, is that in which the incision ofthe larynx is the least extensive. It isto this proceeding that I attribute the cureof the patient. I propose to call the ope-ration I have just described restricted thy-rotomy (thyrotomie restreinte).”

It will be observed that M. Krishaber hasvery materially modified his opinion pre-viously expressed in regard to the necessityof injuring the vocal cords, in making sectionof the thyroid cartilage.

M. Krishaber’s paper is supplemented bya report by Dr. F. Guyon, to whom thesubject seems to have been referred, whichapproves ofKrishaber’s method of operat-ing in the case reported, and says that thy-rotomy alone gives direct and completeaccess to the larynx, particularly to theventricular cavities. It says that sub-hyoidlaryngotomy practised according to the in-structions of Malgaigne only gives accessto the vestibule of the larynx, that is, toparts accessible per vias naturales, and thatfurthermore this operation requires exten-sive incision, and that it is only at the bot-tom of a very deep wound that the surgeonperceives, with difficulty, the ary-epiglotticfolds and the ventricular bands. Whenthe incision is made nearer the thyroid car-tilage, as was performed by Follin, aneasier access is gained to the larynx, par-ticularly to the posterior part.

To reach the larynx by the course fol-lowed by Follin, it is necessai’y to divide abursa and a cushion of fat often quite ex-tensive, to detach the epiglottis from itsinferior attachment and to raise it. Sectionof the crico-thyroid membrane gives suffi-cient space to introduce a canula or instru-ments, but it does not permit one to seeinto the laryngeal cavity, it does not ne-cessitate a deep incision, but it exposes toinjury the little crico-thyroid artery, hemor-rhage from which is not without gravity,on account of the liability of the blood torun into the air passages.

Notwithstanding the fortunate resultswith regard to the voice which have beenobtained by M. Krishaber and others, aftersection of the thyroid, considering the un-fortunate results obtained by other opera-tors and the results of experiments uponthe cadaver, the report does not regard theoperation to be without serious danger tothe voice, but does not consider this a

4

contra-indication in cases where thyrotomyis indicated. In regard to the restrictionof the operation proposed by M. Krishaber,the report considers that oftentimes incase of multiple sessile polypi, section ofthe thyroid cartilage alone might not givesufficient room for operation. In all thesecases, there is always time, as M. Krisha-ber thinks, to enlarge the incision by divid-ing the membranes longitudinally. Balassahas twice incised the crico-thyroid mem-brane transversely, in order to separatemore freely the two parts of the thyroid.This resource could be employed if theseparation allowed by the longitudinal in-cision were not sufficient.

It has been sufficiently demonstrated thatsimple thyrotomy gives sufficient space foroperation within the larynx, for operatorsto impose upon themselves the rule only topass the limits of the cartilage, when, inthe course of the operation, necessity com-pels them to do so.

Dr. Cutter, in a monograph entitled,Thyrotomy for the Removal of LaryngealGrowths, Modified (Boston, 1871), recom-mends, “ In the operation for the removalof growths in the larynx by section of thethyroid cartilage to hold the use of trache-otomy and the tracheotomy tube as a re-serve measure.’7 Dr. Cutter is certainlyentitled to all the merit of originality inthis method of operating, for he seems notto have been aware of the operations ofpure thyrotomy which preceded this ; butwe cannot call it the “American method,”as it was done by others before he did it,and has been performed about an equalnumber of times in this country and inEurope, for the removal of growths, nottaking into account the numerous opera-tions of this kind for the removal of foreignbodies. The first operation of simple thy-rotomy of which we have any record wasperformed by Brauers de Louvain, in 1833(Krishaber, Diction. Encyc., p. 162). Deb-ron reported a case to theSociete de Chirur-gie de Paris, March 30th, 1864 ( Gazette desHopitaux, 1864, Nos. 76, 87, 88), (Krisha-ber), in which he attempted sub-hyoidlaryngotomy, was obliged, on account ofthreatened asphyxia, to perform thyrotomyand finally to perform tracheotomy, thecricoid cartilage having been left intact.Koeberle (Gazette des Hopitaux, Jane 7th,1866j, reports a case in which he performed“Laryngotomie d’emblee sans Tracheoto-mie,” for the removal of a growth, June19th, 1865. In Dec., 1864, Gilewski madea section of the thyroid cartilage and ofthe crico-thyroid membrane for the re-

moval of polypi (Wiener Med. Wochenschr.,28 Juni und Juli, 1865. British MedicalJournal, Sept,, 1865), (Planchon). Theoperation has been done twice since thattime by Balassa, and once by Krishaber,whose case, an abstract of which was pub-lished in the Medical Times and Gazette,Nov. 20th, 1869, was remarkable from thefact that the patient spoke with a perfectlynormal voice immediatelyafter the operation.

Schwebel (These de la LaryngotomieThyroidienne et de ses Indications, Stras-bourg, 1866,p. 17), sajm the operation of la-ryngotomy being decided upon, if the patientis afflicted with intense dyspnoea, ifsuffoca-tion appears imminent, one should com-mence by practising tracheotomy and in-troducing a canula in order to -make sureofrespiration, or rather should make laryn-go-tracheotomy by an incision of two ringsof the trachea and of the cricoid cartilage.When, on the contrary, it has been decidedto operate on a polyp which has not causedvery serious trouble in respiration, andwhen asphyxia is not imminent, one canproceed to thyroid-laryngotomy withoutpreliminary tracheotomy.

Laryngotomia Thyreoidea Lateralis.Luschka (Der Kehlkoph des Menschen,Tubingen, 1871, p. 19) suggests this ope-ration which has thus far only been per-fox-med on the cadaver. It is recommended,in case of neoplasm in the ventricle ofMorgagni, when, from any cause, medianthyrotomy does not seem advisable, or incase of any affection of the wall of the ven-tricle, removable by operative procedure.By this operation, it is proposed to openthe ventricle of Morgagni without expos-ing the vocal cord or its muscle to anydanger of injury.

This suggestion is founded on the wellknown fact, that the ventricles of the larynxextend upward on each side to the neigh-borhood of the upper border of the lateralwings of the thyroid cartilage.

The long axis of the ventricle runs nearlyin the direction of a vertical line, drawnbetween the first and second quarter of thehorizontal distance, between the incisurathyreoidea superior and the posterior bor-der of the thyroid cartilage. This verticalline indicates the direction of the incisionfor lateral thyrotomy, in the execution ofwhich it is necessary to divide the skin,the muse, sub-cut. colli, the muse, sterno-hyoideus, as well as the thyroid cartilagefrom top to bottom. After the edges ofthe cartilage have been drawn asunder byblunt hooks, the upper end of the ven-tricle of Morgagni comes into view in such

5

a manner that there is no difficulty in con-tinuing the incision through its lateral wallas far as the level of the upper surface ofthe vocal cords.

Dr. Mackenzie, in a letter {Lancet, Dec.2, 1871), replying to certain remarks ofMr. Durham in the Royal Medico-Chirurgi-cal Society, reiterates the opinion expressedin his Essay on Growths in the Larynx,considering it “a cardinal law that an extralaryngeal method ought never to he attempted(even when laryngoscopic treatment cannotbe pursued), unless there be danger to lifefrom suffocation or dysphagia.”

Perichondritis Laryngea. —A case is re-ported in the British Medical Journal, July13th, 1812, which seems to have been oneof perichondritis laryngea; it occurred atthe Hull Infirmary under the care of Dr.G. F. Elliot. The case is remarkable fromits having occurred in a robust man with-out any history of syphilis or other consti-tutional disease, and from its having re-covered without any necrosis. Ten weeksbefore admission, and shortly after the ces-sation of what seemed a slight cold, thepatient noticed a difficulty in swallowing,and also that respiration was somewhat ob-structed, especially on making any exertion.When these symptoms had existed for abouta month, he observed that his neck washarder and larger than natural, and thiscontinued gradually to increase. On hisadmission, the most noticeable feature wasthe great increase in the antero-posteriordiameter of the neck ; the swelling wasevidently situated in the thyroid cartilage ;

it was hard, painless on pressure, and pre-sented no indication of suppuration. Hewas ordered an iodide of potassium mix-ture, and the local application of iodide ofammonium ointment. On the 28th ofFeb-ruary, he was suddenly seized with a com-plete obstruction to respiration. Mr. Plax-ton, the house-surgeon, having been imme-diately summoned, with great promptitudeopened the trachea, and respiration (all at-tempts at which had ceased) was happilyrestored by intermittent pressure on thethorax. The necessary incision gave ventto a quantity of somewhat glaiz-y-lookingpus. From this time, the man’s improve-ment was uninterrupted, the swelling ofthe neck gradually subsided, and the thick-ened thyroid cartilage became nearly re-duced to its natural dimensions. The tubewas removed on the 7th of May, rathermore than two months after its incision ;

the opening rapidly closed, and on the Ilthof May, he was discharged, well.

Double Tone of the Voice in unequal Ten-

sion of the Vocal Cords.—Dr. M. J. Ross-bach ( Virchow’s Archiv, April 11th, 1872)reports two cases of special interest withreference to the physiology of the voice,in which, during partial paralysis of onevocal cord, there were produced two tonesinstead of one, clearly distinguishable fromeach other. One tone had always the cha-racter of a chest-tone, the other that of afalsetto, Thq affected cord was seen to bestretched somewhat, but was not renderedso tense as that on the sound side. On at-tempted phonation, the arytenoid cartilageswere not brought up quite to the medianline ; hence there was not a complete clo-sure of the glottis. Dr. R. says that thisformation at the same time of two tonesby two unequally stretched cords, which,of course, were much weaker and less clearthan a normal tone, admits probably ofno other interpretation than that theyhave been formed by the vibrations of thevocal cords themselves. For, during theprocess of phonation the chink of the glot-tis was several millimetres wide and theprocessus vocales of the arytenoid carti-lages did not even touch each other, so thatthere could be no interrupted currents ofair. Then, again, it is hard to think thatone and the same current of air, set into un-equal vibrations by not equally rapid move-ment, should be divided into two tones.

Cases have been reported by Merkel andTiirck in which a double tone was producedby a collection of mucus between the vo-cal cords and ventricular bands, and bygrowths and polyps on the vocal cords,dividing the glottis into unequal parts, butthe above are the first cases reported inwhich a double tone was produced by une-qual tension of the vocal cords.

Papilloma of the Larynx; Warts on theHands. —Dr. Paluce de Marmon (iV. Y.Med. Record, Oct. Ist, 1872) reports thecase of a patient 51 years of age, who hadhad whooping cough at 4, lasting four orfive months. This was followed by hoarse-ness and aphonia. A homoeopathist hadtold the parents that the child “ would out-grow it.” Instead of this, however, itdied suddenly of asphyxia. On post-mor-tem examination, a large papillomatousgrowth was found in the larynx. Therewere also half a dozen warts on the backsof the hands. Dr. M. is inclined to thinkthat there was a connection between thetwo growths.

Primitive Cancer of the Larynx. —Dr.Emile Blanc (Etude sur le Cancer primitifda Larynx, Paris, 18V2), at the end of his

6

monograph, draws the following conclu-sions:

“1. Primitive cancer of the larynx is arare affection ; the number of observationsof laryngeal tumors in general, hithertopublished, is very considerable ; that ofcancer of this region is limited to less thanthirty.

“2. The point of origin and the seat ofelection of cancer of the larynx, is espe-cially the mucous membrane of the ventri-cle of Morgagni.

“ 3. The principal varieties of cancer ofthe larynx are medullary cancer and epithe-lioma.

“4. Left to itself, cancer of the larynxinvades the neighboring tissues, contract-ing the respiratory passages and those ofdeglutition. The cartilages of the larynxoppose for a long time the progress of thedisease, but they end by being involved intheir turn, and then the progress of thetumor is arrested only by the death of thepatient.

“5. At the beginning of the affection, inspite of the most careful laryngoscopic ex-amination, it is very difficult to recognizethe cancerous nature of a laryngeal tumor.Later, the rapid extension and the peculiaraspect of the neoplasm, the ganglionic en-gorgement and the final cachexy make thediagnosis certain.“ 6. The treatment recognizes two prin-

cipal indications:a. To remove the disease.b. To palliate the most urgent symptoms

and especially the threatening of asphyxia.This last indication is fulfilled by tracheoto-my, the first by the extirpation of the tu-mor. According to the case, this removalis practised by the mouth or by differentprocedures of laryngotomy.

“ Laryngotomy is always indicated whenthe tumor is not accessible by the naturalpassages, or when by this latter means wedo not succeed in the total destruction ofthe neoplasm. In conclusion, howeverwell practised and however radical it maybe, extirpation is constantly followed, some-times by local recurrence, sometimes bysecondary generalization, and finally bydeath by cancerous cachexy. Always, ifone does not succeed in saving the life ofthe patient, at least he mitigates and pro-longs it. It was thus that in the case ob-served by M. Desormeaux laryngotomypermitted the subject to survive for threeyears. Here, then, as in other analogouscircumstances, surgical art by interfering

fulfils its mission, which is to soothe ifnotto cure.”

The Electrolytic Treatment of Naso-Pha-ryngeal Polypi. —Dr. Paul Bruns, assistant inthe surgical clinique at Tubingen, in an arti-cle on this subject (Berliner Klin. Woch-ensch., July 1,1872), reports a case* treatedin the clinique of his father, a short notice ofwhich has already appeared in the latter’swork on “ Galvano-Chirurgie.” A youngman nineteen years of age, with a largenasb-pharyngeal polypus, appeared at theclinique in November, 1865. Treatment bymeans of Electrolysis was attempted, butgiven up after six applications on accountof want of noticeable improvement and ofthe proper apparatus. In December, 1866,the tumor was extirpated by means of awire sling, but there remained a small part,which could not be immediately removedon account of profuse bleeding and faint-ness. The patient appeared again at theclinique towards the end of the year 1868.The tumor had grown to a much greatersize than before the extraction.

It now caused a very considerable dis-figurement of the face, which was notice-able at the first glance. Nearly the wholeofthe left half of the face appeared pushedup, the left half of the nose was noticeablybroadened, the left nostril much dilated andfilled up by a pale-red smooth swelling.The fossa canina and temporalis of thesame side were filled up, the whole cheekpushed forward. The globe of the left eyestood several lines farther forward, and wasat the same time displaced outwards anddownwards. In consequence of this, thereexisted diplopia, incomplete closure of thelid and impaired action of the internal rec-tus muscle.

The pharyngeal cavity was nearly com-pletely filled up with a very resistent tumor,which pushed forward between the edgesof the artificial slit in the soft palate, whichwas made previously to the first operation,into the mouth and downwards as far as thelower end of the uvula.

Both nostrils were impervious to the air,the left in consequence of complete stop-page by the nasal part of the polypus, theright in consequence of the pushing of theseptum towards this side, and the closureof its posterior opening by the growth.Respiration and deglutition were rendered

* An allusion to this article has been already made inthe report on Electro-Therapeutics, Oct. 31, 1872, butthe great importance of any aid in treating this mosttroublesome affection leads me to give the details of Dr.Bruns’s case, and some particulars not given by Dr. Lin-coln.

7difficult. Hearing on the left side and thesense of smell were entirely lost. Thereexisted also a condition of great generaldebility and frequent somnolency. Fromthe above appearances the diagnosis of aso called retro-maxillary tumor (Langen-beck) was made, the extirpation of whichit was thought could only be made bymeans of a temporary (osteoplastic) resec-tion of the upper jaw. Instead of this, theattempt to destroy the tumor by electro-puncture was repeated, and this treatmentwas commenced May 2d, 1869. The elec-trolytic treatment was continued to the endof March, 1810, and during these elevenmonths there were made one hundred andthirty applications, sometimes daily andsometimes at the interval of one or severaldays. The duration of one application wasten to fifteen minutes. After the first sit-ting, the left nostril was a little perviousto the air; after the tenth sitting, there wasan evident diminution in the size of thepharyngeal part of the polyp. It continuedgradually to diminish in size, and after fortysittings the anterior end of the nasal partwas three centimetres removed from theedge of the nostril. There was notable im-provement in breathing through the nose,the globe of the left eye was less promi-nent, its movement less hindered, and therewas no diplopia. After sixty sittings noexophthalmos existed; the nasal part ofthe tumor was four centimetres from thenasal opening. After eighty sittings thepolyp was five centimetres from the nasalopening; the pharyngeal part was no longervisible in the cleft of the palate, and couldonly be reached by means of a curvedneedle. After one hundred sittings, byrhinoscopic examination there was seen inthe remainder of the tumor, which was ofthe size of a walnut, a deeg ulcerating holecovered with purulent secretion which wassoft to the touch, friable, and surroundedby resisting edges. After one hundred andthirty sittings, at the conclusion of thetreatment, the outward deformity of theface, the prominence of the whole left upperhalf of the face, and the dislocation of theglobe of the eye had disappeared. Bothnostrils were pervious to the air, the nasalpart of the polyp had entirely disappeared,the pharyngeal part was no longer visiblein the cleft of the palate, and only a hardknot of the size of a bean remained on theposterior edge of the vomer. .Respirationand deglutition were unimpeded; hearingin the left ear was nearly normal. Up toMarch, 1872, there had been no sign of arecurrence of the growth in this patient;

he had remained in the hospital as an atten-dant.

Dr. Bruns then gives abstracts of eightother cases of naso-pharyngeal polypi,which had been successfully treated byelectrolysis. Five had been observed byNelaton, two by Ciniselli, and one byFischer.

In six of these, there was a completecure, and in the remaining two the cure wasincomplete ; in the first in consequence ofintercurrent typhus fever, which provedfatal, and in the second because the reportwas made before the conclusion of the treat-ment. In none of these cases had a recur-rence occurred. The duration of the treat-ment in those cases where it is stated, isreported to have been as follows : six sit-tings, nine sittings at long intervals, six sit-tings within six weeks, and six sittingswithin about three months. In these cases,where the application was made at suchlong intervals, the current employed was ofmuch greater intensity than in the case ofProfessor Bruns. In one of Nelaton’s casesan operation had been previously performedby means of re-section of the hard palate,and there was a recurrence of the growthafter three months. Eight months afterthe cure by electrolysis, there had been norecurrence.

Dr. Bruns does not claim that this methodof treatment can be employed with successin all cases, and, indeed, mentions a casealreadyreported by himself [Berliner Klin.Wochenschr. 12 u. 13, 1812), in which, afterunsuccessful employment of electrolysis,extirpation was performed.

The histological character of the tumorssuccessfully operated upon by electrolysisseems to have been fibrous ; in the one un-successful case the tumor is described asbeing composed of a tissue in part purelyfibrous, and in part very rich in cells ap-proaching the sarcoma. Contrary to thecustom in the treatment of tumors situatedin other parts of the body, experienceseems to show that it is better to employa weak current, frequently repeated, than astrong one at longer intervals ; the closeproximity of the brain and the serious localdisturbance which might be set up by thestrong current, would indicate caution inthis respect.

Dr. Bruns does not consider that in anybase a diminution of the tumor was due tocatalytic or escharotic action alone, but toboth combined. In conclusion, Dr. Brunssays that there is inducement enough in pre-vious experience to warrant the employmentof electrolysis in other cases, even if we

8

cannot share the enthusiasm of Dolbeau,who characterizes its employment as “ unemethode qui parait destinee a faire dispa-raitre toutes celles qui I’ont precedee.”

On the Differential Diagnosis and Treat-ment of Bronchocele.—Dr. Morell Macken-zie (Lancet, May 4th and 11th, 1872)gives an interesting paper on this sub-ject, which he had read before the Hunteri-an Society.

He says that since Coindet discoveredthe medicinal value of iodine, the therapeu-tics of goitre have - remained almost sta-tionary. Whilst, however, iodine exercisessuch a beneficial influence over some formsof goitre, in others it is quite inoperative,and hence it becomes important to differ-entiate the varieties of the disease whichare met with in practice. Dr. Mackenziedivides bronchocele into seven varieties,viz. : (1) simple or adenoid, (2) fibrous,(3) cystic, (4) fibro-cystic, (5) fibro-nodu-lar, (6) colloid, and (7) vascular.

The disease may present the characteris-tic features of any one of the types referredto, or many of the different varieties maybe associated together in varying degrees.The internal administration of iodine is aspecific for the endemic variety of simpleor adenoid bronchocele; and, though itlikewise often cures sporadic cases, it is fre-quently unavailing.

Simple hypertrophy occurring in weakanremic girls, is most effectually treated byiron and proper hygienic measures. Casesnot yielding to internal treatment may al-most invariably be cured by counter-irrita-tion, or the internal and external treatmentmaybe combined. The liquor epispasticusof the British Pharmacopoeia, applied abouttwice a week on alternate sides of thethroat, is the remedy which Dr. M. usuallyemploys. Electrolysis had also proved ofgreat service in some cases. Of the fifty-four cases of simple goitre of which noteswere taken, forty-seven underwent treat-ment. In thirty-five the enlargement en-tirely disappeared, five were lost sight ofafter a few visits, and in seven no appreci-able alteration took place.

Fibrous Bronchocele may. attack eitherlobe, the isthmus, or the whole gland, butit is comparatively rare that the isthmusalone is affected. To the touch fibrousgoitre is smooth, hard, and unyielding. Itdoes not, as a rule, cause any disturbance offunction, but in some cases it presses onthe trachea and produces dyspnoea. Whenonce established it never disappears spon-taneously, though it may occasionally bedeveloped into the fibro-cystic or fibro-

nodular varieties. The treatment whichhas been found most successful in this va-riety by Dr, M., is the introduction of atwine seton passed transversely throughthe whole substance of the gland.'

Counter-irritation, or applications oftincture of iodine or iodine ointment, orthe injection of a solution of iodine, haveproved quite unavailing. Out of one hun-dred and one cases of the fibrous varie-ty which came under notice, in thirty-onethe tumor was so small and the inconve-nience so slight that treatment was notrecommended; and nine patients, who weretold that the disease was not dangerous tolife, declined treatment. Of the remainingsixty-one, in forty-two the result was com-pletely successful. In eleven, there wasconsiderable improvement ; in five, nochange, and in three the parties ceased toattend before the result could be ascer-tained. In the two illustrative cases intro-duced by Dr. M., the dyspnoea was relievedwithin a day or two after the introductionof the seton.

The treatment of cystic goitre which Dr.M. likes best, is the conversion of the cystinto a chronic abscess. The treatmentwhich most rapidly produces suppurationalso most effectually arrests the haemor-rhage. The method of procedure is as fol-lows: Ist. Empty the cyst; when prac-ticable, make the puncture as near as possi-ble to the median line in the most dependentportion of the tumor. As soon as thetrocar is felt to pierce the cystic wall, itshould be withdrawn and the canula passedfurther in by means of a blunt pointed key.The fluid having been withdrawn, a solutionof per-chloride of iron (two drachms to theounce), is injected through the canula bymeans of a syringe, the plug is inserted,and the canula secured in position by a stripof plaster. Tl*e injection of iron is repeatedat intervals of two or three days until sup-puration is established. When this pointis reached, the tube is withdrawn, poulticesare applied, and the case treated as achronic abscess. When there is more thanone cyst, the others can frequently beopened through the cyst originally punc-tured, and in this way some scars may beavoided. Of thirty-nine cases of cysticgoitre, thirty-eight underwent treatment;all of these were completely cured.

The treatment of a case of fibro-cysticgoitre consisted in the evacuation of thecysts and the injection of iron, and afterthe obliteration of the cysts, the introduc-tion of a drainage-tube, from left to right,through the entire mass.

9

Great induration remaining, two causticdarts were introduced. By this treatmentthe circumference of the throat was reducedfive inches and a half.

In fibro-nodular bronchocele, treatmenthas seldom any beneficial effect.

Of two reported cases of colloid bron-chocele, one was treated by electrolysis, andthe other by a seton, both unsuccessfully.Dr. M. thinks that with his increased expe-rience both of these cases might have beensuccessfully ti’eated by irritating setonsor caustic darts.

No case of the vascular form of bron-chocele occurred. The rule which Dr.Mackenzie has adopted with reference tothe advisability of surgical interference incases of goitre is, not to •recommend patientsto undergo treatmentunless there is seriousembarrassment of function or continuousincrease of the tumor ; but, as none ofthevarious methods of treatment employed byhim have hitherto been attended by fatalresults in his practice, he has always beenwilling to carry out treatment when thepatient desired it, on account of disfigure-ment.

Paralysis of the Abductors of the VocalCords.—Dr. Franz Riegel, Privat-Docentand First Assistant in the Medical Cliniqueat Wurzburg (Berliner Klin. Woch., May18th and 20th, 1812), says that paralysis ofone or a few muscles of the larynx is sel-dom met with; but when it does occur, itis generally myopathic ; much more rarelydoes it happen that only a single muscle ora small group of muscles is paralyzed inconsequence of a central lesion, or one af-fecting the vagus and recurrent. He be-lieves the opinion of Gerhardt, that, in caseof an affection of the recurrent only, a sin-gle group of muscles may be paralyzed,namely, the adductors and tensors, to becorrect, notwithstanding the opposition ofNavratil; and refers to a case reported byhimself* in which paralysis and change inthe voice came on immediately after an op-eration in a case of struma, evidently frominjury to the recurrent nerve. The paraly-sis affected only a part of the muscles ofthe vocal cord on the side of the injury ;

the widening of the glottis was completelyunimpeded. Those cases in which the pa-ralysis is incomplete must not be consi-dered as myopathic ; for in an affection ofthe recurrent the paralysis may be incom-plete at first, and afterwards become com-plete. It seldom happens that paralysis ofthe vocal cords, under ordinary conditions,leads to disturbance of the respiration.Complete paralysis of the recurrent on bothsides, under ordinary circumstances, at

* Deutsches Archiv far Klin. Med., Band 6.

least, causes no dyspnoea, but completeloss of voice, difficult expectoration andimpossibility of forcible cough. There isthe same want of dyspnoea in complete pa-ralysis of the recurrent on one side. Thisis easily explained from the position of oneor both vocal cords in these cases. Withreference to this point, the views of differ-ent authors seem to differ considerably.Many pathologists have spoken of paraly-sis of the recurrent when the paralyzed vo-cal cord is displaced nearly or quite up tothe median line. Such a conception seemsto Riegel to be erroneous. Complete pa-ralysis of the recurrent can never result ina position of the vocal cord exactly on themedian line. He does not deny that sucha median position can be the consequenceof an affection of the recurrent, as a neuro-pathic paralysis; but in the peculiar me-dian position of the vocal cord there isnever a paralysis of all the muscles of thelarynx.*

From this position of the glottis in com-plete paralysis of the recurrent, the wantof dyspnoea, at least under ordinary cir-cumstances, is easily explained. The me-dian position, however, pre-supposes anactivity of the vocal cord ; it can only oc-cur through action of the adductors, and,therefore, can never he observed in com-plete paralysis of the cord. Neither ismuch dyspnoea possible in this form of pa-ralysis, as there is still sufficient room forinspiration and expiration, as the glottisnow in a manner assumes a mean position,the resultant of those two positions, whichcorrespond to the two functions of vocali-zation and respiration. The same thingmust naturally hold good for complete pa-ralysis of the recurrent on one side. Here,the conditions for the production of dysp-noea are still more unfavorable. If we ask,on the contrary, which form of paralysis ofthe vocal cords produces dyspnoea, it isevidently the paralysis of the adductors.This form, also, of paralysis, like the com-plete paralysis of the recurrent, can occuron one or both sides. Paralysis of theabduc-tors, while the adductors remain intact, isnot followed by a mean position of the vocalcords and arytenoid cartilages. One wouldhere, indeed, expect the same position ason the cadaver, with the possibility of ap-proximation to the median line on intona-tion. Observation shows, however, thatthis does not occur, or at least such a con-dition has not been seen in those caseswhich have been considered paralysis ofthe abductors. The picture of paralysis of

* Complete paralysis ofall the muscles of the larynxwill produce only the post-mortem position of the vocalcord, and the ary tenoid cartilage.

10

the abductor is characterized as follows :

The vocal cord and arytenoid cartilage ofthe affected side stand near the median lineimmovable ; on deep inspiration, the corddoes not move outward, but sometimes alittle inward; its capacity for tension andvibration is not materially limited ; thevoice, therefore, shows no essential change.It may be easily conceived how, on rela-tively little exertion, dyspnoea can arisefrom this median position of the paralyzedvocal cord. As the glottis-chink is dimin-ished by one-half, the increased demandforair during any marked bodily exertion can-not be satisfied, and dyspnoea is the result.The only abductor of the vocal cord is thecrico-arytenoideus posticus. Paralysis ofthe abductor, therefore, is paralysis ofthis muscle. Paralysis of the abductorson both sides occurs very rarely.

After citing the cases of Gerhardt, Tiirckand JBiermer, Riegel introduces one of hisown, in which there was paralysis of thecrico-arytenoideus posticus on each side.The patient, a child 4 years old, was saidby his parents frequently to throw hjs headstrongly backwards and stretch his throat.On increase of dyspnoea, this position wasparticularly noticed by his parents. A sim-ilar condition obtained in Gerhardt’s case,who explained this by the power of thehyo-thyroideus, as antagonist of thecrico-thyroideus, to approximate the thy-roid cartilage to the arytenoids with relaxa-tion of the vocal cords, and so to diminishthe contraction of the glottis caused bytension of the same. The question remainshow the position of the vocal cords, whichhas been mentioned as occurring in case ofparalysis of the abductors, is produced.According to theory, paralysis of the ab-ductor, like complete paralysis of the re-current, would manifest itself by the ordi-nary post-mortem position of the vocalcord. It would thenbe distinguished fromcomplete paralysis of the vocal cord by theexistence of the power of adduction, andfrom paralysis of the adductor from thewant of ability to move outward from thepost-mortem position. Instead of the post-mortem position, however, we find thevocal cords much nearer.the median line.We see, therefore, an increased activity ofthe antagonistic muscles, as we see a pre-ponderating contraction of the flexors inparalysis of the extensors. So we candesignate this appearance as paralytic con-traction of the vocal cord in the same wayas we notice the secondary contractions inparalysis of the extremities. The occur-rence ofsuch contractions in case of paraly-sis has been accounted for by the so-calledantagonistic theory, whereby, in conse-quence of the tonicity of the non-paralyzed

muscles, the limb is drawn gradually toone side. But in the larynx. Dr. Riegelthinks a negative factor is more important.When the vocal cord, in case of paralysisof the abductor, is brought into a state ofadduction by intonation, cough, expectora-tion, &c., the power to widen the glottisagain is wanting ; the cord retains the po-sition into which it has been brought, withthe exception of what change may be dueto a relaxation of tension. In case oftotal paralysis of an extremity, the flexorsovercome the extensors. In the larynx, onthe contrary, respiration being a more im-portant function than vocalization, we seethe abductors overcome the adductors incase of complete paralysis. Hence theconsiderable drawing outward of the cords.If, on the contrary, only the abductor isparalyzed, the adductors obtain the prepon-derance, and hence a position results nearthe median line. This last position mayonly be arrived at gradually. Dr. Riegelalludes to the great rarity of bi-lateral pa-ralysis of the abductors, and says thatGerhardt’s case is the only other true onewhich has been published ; one or morecases, however, have been published byMackenzie, and two by the writer.*

Successful Tracheotomy performed ona Child of Ten Months (Union Medicate,1812, No. 18); ( Centralblatt fur die Med.Wissenschft, Aug. 23, 1812). Dujardin re-ports a case of croup in a child ten monthsold, in which tracheotomy was performed.It was necessary to wear the canula eightmonths. Now, after four years, a small,tracheal fistula exists. The reporter in theCentralblatt says this is the sixth success-ful case of tracheotomy in children undereighteen months reported in France.

A Eemedy for Coryza.—E. Brandt (Ber-liner Wochenschrift. No. 12 and 18) ; ( Gen-tralb. fur die Med. Wissensch., No, 29, 1812)reports that for many years he had sufferedevery autumn with intense coryza,_lastiugseveral weeks, and that he has obtained avery favorable effect from the “ OlfactoriumAnti-catarrh-oicum ;; of Dr, Hager (acidcarbol. 5 parts, spir. vini rectif. 15, liq.ammonim fort. 5, aq. dest. 10) inasmuch asthe coryza was cured after one day’s ex-istence in the first stage, and without, asformerly, invading the trachea.

A few drops of the mixture should bepoured on blotting paper and inhaled, carebeing taken to protect the eyes.f

*Boston Medical and Surgical Journal, Feb. 25th.and Sept. 30th, 1869.f Writers ofpapers on theDiseases of the Throat and

Chest will contribute much assistance in the preparationof the semi-annual reports in this department if theywill forward copies of their papers, addressed to thisJournal.—Eds.